One Vision. Yours.

Referral Guide
One Vision.
that wants great vision to be hassle-free, every day
Yours.
Also available online at
eyeclinicwi.com/od-portal
Thank you for choosing the
Eye Clinic of Wisconsin!
Referring your patient to the Eye Clinic of Wisconsin, SC
Scheduling Tips
Scheduling a patient for a Medical Consultation
Complete the ‘Request for Consult’ Form
Copy both sides of insurance card(s)
Fax all to the Patient Service Representative Fax Line at (715) 261-8665
A Patient Service Representative will contact the patient to schedule and fax an
appointment confirmation to you.
Scheduling a patient for a Cataract Surgery Consultation
Complete the ‘Referral for Cataract Surgery’ Form
Copy both sides of insurance card(s)
Fax all to the Patient Service Representative Fax Line at (715) 261-8665
A Patient Service Representative will contact the patient to schedule and fax an
appointment confirmation to you.
Please advise contact lens wearing patients that they should not wear their contact
lenses for one week prior to the appointment
Scheduling a patient for Special Testing Only - No Exam
Complete the ‘Special Testing Only’ Form
Copy both sides of insurance card(s)
Fax all to the Patient Service Representative Fax Line at (715) 261-8665
A Patient Service Representative will contact the patient to schedule and fax an
appointment confirmation to you.
All Form Masters and Instructions are Available at:
www.eyeclincwi.com/od-portal/
Please call Liz Masanz, Optometric Liaison, at (715) 261-85300 with questions or concerns.
Physician Resource Site
At the Eye Clinic of Wisconsin, we value our relationship with our optometric partners. In order
to ensure ease with the referral process we have developed an additional tool for your use.
At www.eyeclinciwi.com/od-portal/, you will find many features, including:
Information about the Eye Clinic of Wisconsin’s physicians and their specialties
Office Locations
The most up to date referral process and referral forms
Calendar of Events
Marketing Materials
We invite you to explore today.
Accessing the Site
Go to www.eyeclinicwi.com/od-portal/
In order to log on to the Portal, enter:
Username:
localod
Password:
onevisionyours
Clinic Updates
Fax Numbers
In order to ensure a streamlined referral process, some of the fax numbers we have printed on
our referral forms have changed. We apologize for any confusion this may have caused you
and your staff.
In order to expedite the referral process, we have assigned one number to use going forward.
(715) 261-8665
Co-Managing
If there are certain insurances that you cannot co-manage with or post-operative visits that you
prefer the patient do at the Eye Clinic of Wisconsin, please let us know. We will add you to our
list and manage your patients accordingly. Questions about billing or co-managing please call
Liz Masanz at 715-261-8530.
Communication you can anticipate for every patient you refer to the Eye Clinic
of Wisconsin.
1. A faxed confirmation when the appointment is scheduled with appointment details:
when, where, and who it is with. We try to schedule the patient within 24 hours of
receiving your request.
2. A letter on the day of the evaluation from the surgeon with a summary and plan.
3. A surgery confirmation if surgery is scheduled indicating what has been scheduled,
when, and where.
4. If co-managing you will receive a note on the day of surgery.
5. A Relinquish Letter if the patient is co-managed with the post op 1 day notes.
6. A Return to OD Letter if the patient is not co-managed with the final post op notes
and refraction.
If you do not receive one of these pieces of communication, please call Liz Masanz at (715) 261-8530.
Surgeon
Specialty
Surgery Types
Locations
Mathew W.
Aschbrenner, MD
Retina
Wausau;
Rhinelander
Robert N.
Beauchene, MD
Douglas T. Edwards,
MD
General
Laser Treatment; Retinal
Detachment Repair; Retinal
Tear Repair; Treatment for
Macular Degeneration and
Diabetic Retinopathy
Cataract/IOL; Yag Cap; Yag PI
Kevin T. Flaherty, MD
Cornea/Oculoplastics
Refractive
Cataract/IOL; iStent; Yag Cap;
Yag PI; Refractive
Vernon C. Parmley,
MD
Cataract/IOL; Transplant;
Pterygium; Yap Cap; Yag PI;
Medical and cosmetic plastic
procedures including Botox
and Lid procedures
Oculoplastics/Pediatrics Medical and Cosmetic Plastic
and Reconstructive
Procedures including Botox,
Juvederm, Brow and Lid
Procedures; Pediatrics;
Strabismus; Trauma
General/Oculoplastics
Cataract/IOL; Yag Cap; Yag PI;
Medical and Cosmetic Lid
Procedures
Glaucoma
Cataract/IOL; Tube Shunt;
Trabeculectomy; Yag Cap; Yag
PI; SLT; ALT
Retina
Laser Treatment; Retinal
Detachment Repair; Retinal
Tear Repair; Treatment for
Macular Degeneration and
Diabetic Retinopathy
Glaucoma
Cataract/IOL; Tube Shunt;
Trabeculectomy ; Yag Cap;
Yag PI; SLT; ALT
Cornea
Cataract/IOL; Transplant;
Pterygium; Yap Cap; Yag PI
Calvin D. Sprik, MD
Refractive
David C. Tuman, MD
General
Christopher M.
Galang, DO
Ferdinand M. Galang,
DO
Matthew G.
Hattenhauer, MD
Thaddeus J. Krolicki,
MD
Christopher J.
Kucharski, MD
Wausau; Antigo;
Merrill; Medford
Wausau;
Rhinelander;
Medford
Wausau;
Rhinelander; Antigo;
Wausau;
Rhinelander; Stevens
Point
Wausau;
Rhinelander; Merrill;
Medford
Wausau;
Rhinelander; Stevens
Point; Antigo
Wausau;
Rhinelander; Stevens
Point
Wausau;
Rhinelander; Merrill;
Wisconsin Rapids
Wausau; Antigo;
Stevens Point;
Wisconsin Rapids
Cataract/IOL; Phakic IOL’s; Yag Wausau;
Cap; Yag PI; Refractive
Rhinelander; Stevens
Point
Cataract/IOL; Yag Cap; Yag PI
Wausau;
Rhinelander; Antigo
Eye Clinic of Wisconsin Locations
Wausau Office
800 N. First St
Wausau, WI 54403
Rhinelander Office
2 E. Ocala St.
Rhinelander, WI 54501
Stevens Point Office
3401 Stanley St.
Stevens Point, WI 54481
Medford Office
101 S. Gibson St. Suite 16
Medford, WI 54451
Antigo Office
109 State Hwy 64
Antigo, WI 54409
Merrill Office
1207 O’Day St.
Merrill, WI 54452
Wisconsin Rapids Office
841 Goodnow Ave. Suite 103
Wisconsin Rapids, WI 54494
Staff Contacts
Optometric Liaison
Questions regarding referral process, co-management,
scheduling, general concerns.
Liz Masanz
715.261.8530
Surgical Director
Oversees all aspects of the ambulatory surgery center.
Kim Goddard
715.261.8750
Business Services Manager
Questions regarding patient scheduling, billing, and
insurance verification and eligibility.
Margaret Kufalk
715.261.8525
Clinical Services Manager
Oversees all aspects of Medical Services area.
Paul Rovang
715.261.8529
Compliance Manager
Questions regarding HIPPA and compliance.
Lynn Patterson
715.261.8527
Surgical Services Manager
Oversees all aspects of Surgical Services.
Barb Lambrecht
715.261.8534
Refractive Surgical Program
Questions regarding surgery, pre-operative arrangements,
follow-up visits and eye examinations.
Cindy Frahm
715.261.8553
Patient Service Representatives
Schedule appointments, pre-operative arrangements
and eye examinations.
800.472.0033
Standard Post Op Schedules
Cataract:
Post op 1 day
Post op 2-3 weeks
Post op 2 must occur prior to the second eye surgery (if applicable)
Lasik:
Post op 1 day
Post op 1 week – can be canceled if stable at 1 day
Post op 1 month
Post op 3 months and 12 months
*All post ops related to the surgery within the first year are included in their fee
PRK:
Post op 1 day
Post op 4-5 days (SBCL removal)
Post op 7-8 days
Post op 1 month
Post op 4-8 weeks and 12 months
*All post ops related to the surgery within the first year are included in their fee
Standard Post Op Schedules
DALK:
Post op 1 day
Post op 3-4 weeks
K-transplant:
Post op 1 day
Post op 3-4 weeks
Retina:
Post op 1 day
Post op 1 week
Post op 1 month
Retina Laser/Cryo:
Post op determined by patient need
Clinic Name
Doctor Name
Street Address
City, State Zip
Phone: 715.999.9999 Fax: 715.999.9999
□Biometry
□Keratometry
□Post LASIK pt.
Referral Form for Cataract Surgery
Dr. Signature
Date: _____________________
Dear Doctor: __________________________________,
Surgeon’s Name
An appointment has been requested for the following patient to see you in your office in ____________________,
for consideration for cataract surgery in the right / left / both eye(s).
(Location)
Name: _____________________________________________________ DOB: _______/_______/_______
Address: __________________________________________________ State __________ Zip __________
Telephone: ___________________________
Alternate Number: _______________________________
The most recent examination was on ___/____/___.
Visual Complaints: ________________________________________________________________________
Sphere
Cylinder
Axis
Prism
Base
Add
Best Corrected Visual Acuity
PL
Most Recent Refraction:
E
________________________________________________________________________________________
x
x
OS 20/_______
SA
M
OD 20/_______
Applanation Tensions: _____OD/_____OS
Optional Additional Information: PAM: 20/____OD
20/____OS
BAT (High): 20/_____OD
20/____OS
Other Pertinent Information/Ocular History:______________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________
_________________________________________
Physician’s Signature
It is my desire to have Dr. ____________, my own optometrist, perform my follow-up care after my cataract surgery.
I have discussed this with Dr. ______________, and he/she has assured me that he/she is qualified to handle my
postoperative care. I have been assured that you will be contacted immediately if I experience any complications
related to my cataract surgery.
________________________________________________
__________________________
Patient’s Signature
Date
APPOINTMENT SCHEDULING
□ Please call patient to schedule, note appointment below and fax back to my office.
□ Please contact patient for billing information.
□ I have already scheduled an appointment on the patient’s behalf, as noted below:
PSR Initials: __________
Date: _______________ Time: ___________ Location: _________________ Provider: __________________
Additional Testing Required
Clinic Name
Dr. Name
Street Address
City, State Zip
Phone: 715.999.9999 Fax: 715.999.9999
Request for Consultation
□AVF
□External Photos
□OCT
□IOL Master
Date:____________________________
Dr. Signature
PATIENT INFORMATION
Patient Name: _______________________________________________________ D.O.B.: ________________________
If Minor- Guarantor’s Name:___________________________________________________________________________
Address: _________________________________________ City: ____________________ State: ______ Zip:__________
Phone #1: ______________________________________ Phone #2: __________________________________________
Insurance Plan: ____________________________________ ID #: ____________________________________ Self-Pay □
Referring Physician: Please fax clear copy of both sides of patient’s insurance card
CONSULT REQUEST
PL
E
I would like to have your assistance with this patient’s care. Please evaluate this patient’s ocular and visual complaints, and
consider treatment as appropriate. I look forward to receiving your opinion and advice regarding care of this patient and would
be happy to resume the general care of the patient following your consultation and treatment and/or recommendations, as
appropriate.
SA
M
For Glaucoma Referrals please send a copy of the patient’s: past visual fields, pressure readings, and a list of ocular medications.
For Strabismus Referrals please include most recent refraction with prism if applicable.
Please describe the condition(s) to be evaluated and past ocular history:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Most Recent Refraction:
Sphere
Cylinder
Axis
Prism
Base
Add
Best Corrected Visual Acuity
x
x
If applicable
OD 20/______
Signature of Provider Requesting Consultation
Signature: ___________________________________________________
OS 20/______
Date: __________________
Preferred Location:___________________ Preferred Ophthalmologist: ____________________ Urgency ___________
APPOINTMENT SCHEDULING
□ Please call patient to schedule, note appointment below and fax back to my office.
□ Please contact patient for billing information.
□ I have already scheduled an appointment on the patient’s behalf, as noted below:
PSR Initials: __________
Date: _______________ Time: ___________ Location: _________________ Provider: __________________
Please fax this completed form to: (715) 261-8665
Please Note:
If an interpretation is requested, the patient must be seen by a Eye Clinic of Wisconsin physician. Please complete a
REQUEST FOR CONSULTATION FORM, instead of this form.
PATIENT INFORMATION
Patient Name:
DOB:
Address:
Phone #1:
Phone #2:
Insurance Plan:
Self-Pay
ID #:
Requesting Physician: Please fax clear copy of both sides of patient’s insurance card

REQUESTING PROVIDER INFORMATION
E
I would like to have your assistance with this patient’s care. Please perform the special testing indicated below.
Doctor’s Signature:
Doctor’s Name:

OD

MD
PL
NPI #:
Practice Name:
Practice Contact:
Practice Address:
Practice Phone:
Practice Fax:
Practice Email:
SA
M
SPECIAL TESTING: REQUIRED INFORMATION
ICD-9 Code:
Glasses RX:
Please fax a clear copy along with this form, and both sides of the patient’s insurance card.
Brief Clinical History:
SPECIAL TESTING REQUESTED
Testing Type :
Please Circle Designated Eye
A-Scan
Immersion
IOL Master
Stereo Photography
Fundus
Disc
OCT (Ocular Coherence Tomography)
Pachymetry
Topography
Humphrey
Pentacam
Visual Field
Sita Fast Humphrey 24-2
Standard Humphrey 24-2
Goldman Visual Field (Lids Only)
Other:
Wausau
Rhinelander
Stevens Point
Antigo
Please Circle Location
OD OS OU
OD OS OU




N/A

N/A

N/A

OD
OD
OD
OD
OD
OD
OD
OS
OS
OS
OS
OS
OS
OS
OU
OU
OU
OU
OU
OU
OU












N/A
N/A
N/A

N/A
N/A
N/A




N/A

N/A

N/A
N/A
N/A
OD
OD
OD
OD
OS
OS
OS
OS
OU
OU
OU
OU

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


N/A


N/A


N/A


N/A
APPOINTMENT SCHEDULING
Please
check all
that apply:

Please call patient to schedule (and fax this form back as confirmation)

I have already scheduled an appointment on the patient’s behalf, as noted below
Appt:
Date:
Merrill/Medford
Time:
Location:
Provider:
Please fax this completed form to: (715) 261-8665
A copy of the test results will be faxed to your office on the day of testing. The original test results will be mailed to you.
Low Vision Referral
Low Vision Program
Date: ____________________
Dear Low Vision Specialist,
E
An appointment has been made for the following patient to see you on the ______________day
PL
of ___________________, 20 ____, in your office for a low vision evaluation.
Name: _______________________________________________ DOB: _________________
SA
M
Address: ______________________________________________State:_______Zip:________
Telephone: __________________________________
Most Recent Examination was on ____ /_____ /_____.
Most Recent Refraction:
Sphere
Cylinder
Axis
Prism
Base
Add
Best Corrected Visual Acuity
x
OD 20/_______
x
OS 20/_______
Other Pertinent Information/Ocular History: _________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________
Physician’s Signature
Please fax this completed form to: (715) 261-8665
800 N First Street, Suite 100
Wausau, WI 54403
Ph: 715.298.5500
Date: ________________
Dear Dr. ____________________________,
Your patient, ____________________________________, D.O.B. ______________ had cataract
E
surgery performed by Dr. ____________________________ today. The surgery went well and
PL
you will be seeing him/her tomorrow for their one day follow-up. If you have any questions or
concerns, please do not hesitate to contact myself or my staff.
SA
M
Your patient had a Standard / Premium / Toric IOL (Axis _______) placed in their right / left eye.
Lens specifications are below.
[Lens Sticker Here]
Their target refraction, based on our lens calculations, is _____________.
Thank you for the opportunity to care for this patient.
800 N 1st Street
Wausau, WI 54403
Ph: 715.261.8500
Relinquish Letter
Date of Report: ___________________________
Dear Doctor ______________________________:
An appointment has been made for __________________________________________
to see you on ________________________. The patient understands that you will now assume
responsibility of the postoperative care. The patient has been instructed to call us at any time if
unable to reach you, for any reason.
Cataract surgery was done on ___________________________________ Right/Left eye
Date
by _____________________________________________________________________.
Special circumstances at the time of surgery included:
________________________________________________________________________
E
________________________________________________________________________
PL
At the time of the last postoperative examination on ___________________, the
uncorrected vision in the operated eye was 20/_______, improving to 20/______ with
________________________. Applanation tension was ______________.
SA
M
Other significant findings: __________________________________________________
_______________________________________________________________________.
The following eye medications are being used: __________________________________
_______________________________________________________________________.
Billing Co-Managed Care:
Relinquish Care Date __________________
OD Assumed Care Date ________________Number of days _______________________
Diagnosis Code: _____________________ Procedure Code: _______________________
Please feel free to call with any questions or comments in regard to this patient’s operative or
postoperative course. The Eye Clinic physician on call is always available if you are unable to
reach the surgeon who did the surgery.
Thank you for asking the Eye Clinic of Wisconsin to share in the care of this patient.
Sincerely,
_____________________________________
Eye Clinic of Wisconsin
Post-Cataract Assessment Report
Patient: _____________________________________________________________ D.O.B. ________________
Last Name
First Name
MI
Assessment Date: ___________________________ Procedure Date: OD ______________OS______________
Surgeon: ________________________________________ Premium IOL: Crystalens* Tecnis MF* Restor* Toric AK LRI
*= Please check Intermediate and Near Vision
Brief HPI/CC:
Assessment
OD ________Day/Week/Month
Uncorrected Visual Acuity:
Uncorrected Visual Acuity:
Dist OU 20/ _____
Inter OU 20/_____
Near OU 20/_____
Dist
Inter
Near
OS________Day/Week/Month
Uncorrected Visual Acuity:
20
/ _____
/ _____
20
/ _____
Dist
Inter
Near
20
20
/ _____
/ _____
20
/ _____
20
Flat K ____________@Axis ___________
Flat K ____________@Axis ___________
Pd: ______________________
Auto Refraction
Steep K __________@ Axis ___________
Steep K __________@ Axis ___________
PL
E
Keratometry
Manifest Refraction
__________________________=20/_____ __________________________=20/_____
_________mmgH
_________mmgH Time _______ am/pm
Clear Trace +1 +2 +3 +4
Clear Trace +1 +2 +3 +4
Flare
Clear Trace +1 +2 +3 +4
Clear Trace +1 +2 +3 +4
Med: _____________________________
Frequency: ________________________
Med: _____________________________
Frequency: ________________________
Med: _____________________________
Frequency: ________________________
Med: _____________________________
Frequency: ________________________
Med: _____________________________
Frequency: ________________________
Med: _____________________________
Frequency: ________________________
Med: _____________________________
Frequency: ________________________
Med: _____________________________
Frequency: ________________________
SA
M
IOP
Method: TA/DCT/NCT/TonoPen
AC Cell
Posterior Capsule
Ocular Medications
Final Rx:
Sphere
Cylinder
Axis
Prism
Base
x
+
x
+
Add
Tech: ____________ Scribe: ___________
Comments/Questions: _______________________________________________________________________
Planned Follow Up Visit: ______________________________________________________________________
OD Signature: ____________________________________ Printed Name: _____________________________
Mail or Fax to: Eye Clinic of Wisconsin, S.C., 800 N. First Street, Wausau, WI 54403 Fax: 715.261.8665