Referral Waiver Form CompanyThis field is for validation purposes and should be left unchanged.HMO and/or Mass Health REFERRAL WAIVER FORM Auburn Westboro Eye AssociatesAuburn Tel: (508) 832-9392 Auburn Fax: (508) 832-2497 auburn@auburnwestboroeye.com Westboro Tel: (508) 366-7461 WestboroFax: (508) 366-5018 westboro@auburnwestboroeye.com Please select an office*Auburn OfficeWestboro OfficeMany insurances require referrals for specialty care (that is, non-routine eye care with a medical ocular diagnosis). Medical services for patients with HMOs or Mass Health must be approved by your Primary Care Provider (PCP). It is the patient’s responsibility to obtain a referral from his/her PCP for specialty services. Your signature below indicates that if you receive specialty care without a referral from your PCP, you may be financially responsible for such services.Patient's Name (First, Last)*Date of Birth*Date of Service** Dr Suzanne Lucash, OD (NPI 1053422592) Dr Jeffrey Cohn, OD (NPI 1316292162) Dr Rebecca McLaughlin, OD (NPI 1639564180) Dr Michael Cohn, OD (NPI 1548377393) Dr Brenda Komari, OD (NPI 1588154835) Signature*Date* MM slash DD slash YYYY NOTE: Most insurances will authorize 6 visits to cover future visits within one year with the same doctor, if you ask. PLEASE FAX REFERRAL APPROVAL TO THE APPROPRIATE OFFICE.
