Scroll

Referral and Authorization Forms

Please click the links below to download our Referral and Authorization Forms.

Surgical Referral Form

For patients referred for Keratoconus, please send the following to help us demonstrate progression for insurance approval:

  • K values – all available K values from the last 5 years
  • Manifest refractions – all available refractions from the last 5 years
  • Clinic notes – all notes that document or support disease progression

Surgery Post-Op Form

Information Authorization Form

Fax Numbers
Sioux Falls(605) 371-7035
Fargo(701) 639-7199
Omaha(402) 401-6420
Bozeman(406) 624-6560
Alexandria(320) 762-8898
Billings(406) 294-1996
South Sioux City(531) 625-3940
Cedar Rapids(319) 362-0655
Northern Colorado(970) 582-1176