Physician Forms

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Audiology Referral Forms

Email Referral Form

Printable (PDF) Referral Form

Ophthalmology Forms

IOL/ Implant Process Instructions

Implant Orders

Lens Order Form

Visian ICL 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