- Provider Referral Form
Download a fillable PDF of our Provider Referral Form
To refer to Metrolina Eye Associates:
Print and fill out the Provider Referral Form, and fax back to us at 704-635-7784.
Referral Phone: 704-774-1165
Referral Fax: 704-635-7784
Referral Email: firstname.lastname@example.org
Our goal is to contact patients within 24 hours. Please be advised, Medicaid can take up to 72 hours to process for eligibility. Thank you for trusting Metrolina Eye Associates with the treatment and care for your patients. We are committed to providing the highest level of care and professionalism to you and your patients.
Required Information for Referrals:
- The referring provider’s name, address, phone number, practice name, email, and NPI number
- Provider’s direct fax number
- To be compliant with the “Meaningful Use Act”, please include the most recent patient demographic information including:
- Date of Birth
- Copy of the medical insurance card, front and back side, and if applicable, their vision plan insurance
- If an insurance referral is required, the patients primary care physician (PCP), which is listed on the card, must issue the referral prior to the patients appointment.
- Copy of the exam notes with the diagnosis and list of all current medications.
If you have your own referral form you prefer to use in lieu of our provided Referral Form, we will accept the form with all attached visit notes only if all the above information is included.
Metrolina Eye Associates contact information 800-628-3937.
Referral Coordinator: Waleska Mendoza Ext 2003 or Direct line 704-774-1165.