• HMO and/or Mass Health REFERRAL WAIVER FORM Auburn Westboro Eye Associates

    Auburn Tel: (508) 832-9392
    Auburn Fax: (508) 832-2497
    auburn@auburnwestboroeye.com


    Westboro Tel: (508) 366-7461
    WestboroFax: (508) 366-5018
    westboro@auburnwestboroeye.com
  • Many 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.
  • 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.
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