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INFORMATION FOR MEMBER CLUBS
Member clubs have the right to refer patients. This is a three-step procedure. The first step is to verify that the patient meets the financial eligibility requirements. The second step is to assure that the patient has been seen by a doctor who states that the diagnosis is an eye problem that requires treatment and care, other than eye glasses or contact lenses. The last step is to fill out the referral form and send it in.
The first of three forms below lists all of the criteria for easy reference. The other two are the Financial Eligibility and Patient Referral forms.
As a result of our current operation and relationship with the California Pacific Medical Center, we are starting a pilot program to reimburse each club part of the transportation expenses. The reimbursement is based on the mileage between the referring club location and San Francisco.
Attached below are two new forms. The first is the actual Reimbursement Request Form with instructions. The second form is an example of how to calculate the mileage needed by the above form.
Forms:
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