Physician Forms

To use the Mass. Eye and Ear forms, you will need to have Acrobat Reader, free software for which can be installed by clicking on the acrobat image:

Audiology Referral Forms

Email Referral Form

Printable (PDF) Referral Form

Ophthalmology Forms

Implant Process Instructions

Implant Orders

Lens Order Form

Affiliated Physician Practice Instructions, Intraocular Lens Policy (Updated May 9, 2006)

1. Authorization to Insert Presbyopic ReSTOR Lens during Conventional Cataract Surgery
2. Authorization to Insert Presbyopic Crystalens during Conventional Cataract Surgery
3. Authorization to Insert Presbyopic Crystalens Aspheric Optics during Conventional Cataract Surgery
4. Authorization to Insert Presbyopic Crystalens HD during Conventional Cataract Surgery
5. Authorization to Insert Presbyopic Toric Lens during Conventional Cataract Surgery

Payment Agreement for Refractive Surgery with PC-IOL Lens Replacement

Payment Agreement for Refractive Surgery with Clear Lens Replacement

Page updated February 27, 2013