Transcript document

REQUEST TO ADD OPTOMETRIST
TO MEDICAL PANEL
I, ____________________________, would like to request that my primary eye care doctor
(Please Print Name)
, Dr.____________________________, be added to your Medical Panel so that I can begin
(Please Print Optometrist’s Name)
receiving comprehensive Vision and Medical services in one location. My Optometrist
is board certified in the treatment and management of ocular disease, and I have
chosen my doctor based on my Optometrist’s ability and training for all of my eye care
needs. I certainly appreciate your consideration in this matter.
Sincerely,
___________________________
__
(Patient Signature)
Health Plan:
_______________________________
Member #:
_______________________________
Employer:
_______________________________
REQUEST TO ADD OPTOMETRIST
TO MEDICAL PANEL
I, ____________________________, would like to request that my primary eye care doctor
(Please Print Name)
, Dr.____________________________, be added to your Medical Panel so that I can begin
(Please Print Optometrist’s Name)
receiving comprehensive Vision and Medical services in one location. My Optometrist
is board certified in the treatment and management of ocular disease, and I have
chosen my doctor based on my Optometrist’s ability and training for all of my eye care
needs. I certainly appreciate your consideration in this matter.
Sincerely,
___________________________
__
(Patient Signature)
Health Plan:
_______________________________
Member #:
_______________________________
Employer:
_______________________________