Referral Waiver Form 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.PhoneThis field is for validation purposes and should be left unchanged.
