Consultation Request

Referring Providers

Due to the Medicare changes regarding requirements for consultations, we have been advised that a written request must be provided for all consultations. We have also been advised that both the requestor and the consultant must document the reason for the consultation in the patient’s medical record.

To deal with these documentation conditions, we are providing a Consultation Request Form that you may photocopy and fill out. You may either fax in advance of the patient’s scheduled appointment, or have the patient bring the form to their visit. If you decide to fax the form, the appropriate fax numbers are listed below. Fax numbers are also provided on the Consultation Request Form.

Effective immediately, please provide a written note when you would like to request a consultation from one of our providers.

We understand that this creates somewhat of a burden for all medical providers; however, we are attempting to make this as easy for you as possible in order to be compliant with the new Medicare regulations. Unfortunately, if we do not receive one of these letters prior to your patient’s appointment, we will need to call you at the time of their visit to fill out this form before we are able to evaluate them. This will lead to unnecessary delays for your patients and more hassle for you.

On behalf of all the providers at Associated Eye Care, we want to thank you for your support and confidence in sending your patients to see us. We also thank you for your cooperation and pledge to continue to deliver the best care possible. We feel that this process will not only benefit our mutual patients, but also improve our ability to communicate with you more effectively.

Fax #s:

651.275.3099 – Stillwater

651.275.3166 – St. Paul

651.275.3135 – Lake Elmo

651.275.3214 – Forest Lake

651.275.3271 – New Richmond

Request a Consult


Patient Name:
Patient Address:

City:
State:
Referring Provider Name:
Clinic Name:
Clinic Phone:
Reason for Visit: