PATIENT DRAWING OF FLOATER(S)
Sketch an image of how you see the floaters. Imagine looking at a bright white board about 1yard/1meter away. Do not be overly concerned about accuracy as we acknowledge that drawing clouds is a difficult task. We are looking for basics such as which quadrant, detailed versus soft and cloudlike. Draw arrows to show typical movement. There is no right or wrong way to do it.

QUESTIONAIRE
This is our patient questionnaire form we will ask you to complete at your first visit for evaluation consultation. Save a few minutes by completing this in advance

LETTER OF MEDICAL NECESSITY
This form may be used as part of an insurance request for reimbursement for the procedure. It explains what significant floaters are, the treatment options available, the pertinent insurance codes used, as well as published references to articles showing the efficacy and safety of treatment.

INSURANCE REJECTION APPEAL LETTER [pdf]: Trying to appeal an insurance rejection? One of my patients familiar with the insurance business submitted this letter and got a favorable judgement on appeal to their insurer.

INSURANCE REJECTION APPEAL LETTER [WORD 2003]: Same as above. Fill in the details as needed.

PROCEDURE FEES
A printer-friendly versions of the consultation and treatment fees explained on our site HERE

PATIENT REFERRAL FORM
For eye care providers. Do you have a patient you wish to refer to our office? Here is a simple, one-page form to help describe and standardize the reporting of your findings.