Surgery Forms
General Forms
Salem Laser & Surgery
Northbank Surgical Center
Checklist General Surgery Consent Overview Cardiac Clearance Form General Clearance Form Fee Estimate Pre-Op Post-Op Instructions Post-Op Instructions Co-Management Release Co-Management Release (IPAD) Health History IOL Informed Consent Surgery Schedule Handout
[ Salem Laser Pre-OP Packet ] [ YAG Laser Flow Packet ] [ Pterygium Packet ] Salem Laser Registration Salem Laser Instructions Salem Laser Lens Request Salem Laser - Northbank (Lens Request) Salem Laser Iridotomy Flow Yag Laser Flow Physicians Order Sheet Salem Laser Special Request Physicians Order Sheet - General Physicians Order Sheet - Lids Pterygium Physicians Order Sheet Salem Laser Health History
[ Northbank Pre-OP Packet ] [ Northbank Packet ] Northbank Surgical Center Scheduling Northbank Instructions Northbank Order Sheet Northbank Order Sheet - General Northbank Laser Flow Northbank Order Sheet - Lids Intraocular Lens Request Northbank Procedure Form Northbank Directions (English) Northbank Directions (Spanish)


History & Physical
Salem Hospital
Miscellaneous
History & Physical History & Physical - Blank History & Physical - Bleph Additional Medications
Salem Health Surgery Scheduling Plan Salem Health Surgery Scheduling Request Salem Health Intraocular Lens Request Salem Health Surgery Change Request Salem Health Insurance Surgery Release Salem Health Day of Surgery - Order for Consent Adult Pre-Operative Orders Adult Pre-Operative Eye Surgery Salem Health Informed Consent Salem Health Informed Consent - Spanish
Authorization To Release Information Authorization To Release Information (Family & Friends) Insurance Referral Request Glaucoma Tests Vitreous Detachment Vitreous Detachment - Spanish Salem Hospital Supply Form Healthnet Outpatient Form CPP Drop Instructions CDP Drop Instructions Cat Sx Eye Drop Options - MAE Cat Sx Eye Drop Options - RWL


LASIK
PRK
Spanish
LASIK Informed Consent Salem Laser LASIK Flow Sheet Salem Laser LASIK Procedure Information Salem Laser LASIK Pre OP Post OP Instructions Salem Laser Autoimmune Surgery Waiver LASIK Enhancement Waiver
PRK Informed Consent PRK Surgery Waiver PRK Pre OP Post OP Instructions
Back Office Forms
Fax Covers
Exam Reports
Authorizations & Referrals
Fax Cover Fax Cover (SALEM HOSPITAL) Fax Cover (SILVERTON HOSPITAL) Fax Cover (SANTIAM HOSPITAL) Fax Cover (Ipad)
Exam Report Exam Report (Ipad) Diabetic Exam Report Diabetic Exam Report (Ipad)
Authorization To Release Information Authorization To Release Information (Family & Friends) OD Referral Letter OD Referral Letter (Ipad Version)
Letters & Notes
Articles & Handouts
Instruction Sheets
Condolances Letter Blank Letter Blank Letter with Signature Return To Work Prescription Pad Letter Template Letter Template (Ipad Version) Office Visit Note Office Visit Note (Ipad Version) Adding Clinics Template
Surgery Schedule Handout Macular Degeneration Article Vitreous Detachment Durysta Handout SLT Handout
Eye Medication Instruction Sheet Eye Medication Instruction Sheet (No Cap Color) Eye Medication Instruction Sheet (Spanish) OTC Drop Sheet
Front Office Forms
Requests
Miscellaneous
Authorization To Release Information Authorization To Release Information (Family & Friends) Insurance Referral Request Patient Registration Medical History Form Blank Word Doc with Header & Footer Recall Label Template CHAOS Medical Records Request
Claim Appeals Letter Excused Absence Excused Absence (Free Type) Records Letter Vision Check Form
Optical Forms
VSP Signature
VSP Choice
Blank Savings
Single Vision Bifocal Trifocal Progressive
Single Vision Bifocal Trifocal Progressive
Single Vision Bifocal Trifocal Progressive Frame Only Savings Statement


Contact Lens Forms
Miscellaneous Insurance
Miscellaneous Forms
Contact Lens Order Form Trial Order Form Contact Lens Savings Statement Contact Lens Handout Contact RX Verification Denial
VSP Option Chart Post OP Billing Instructions Advance Beneficiary Notice (Medicare) OHP Client Agreement
Optical Purchasing Policy Wiley-X Order Form Fillable Paper Order Form Paper Order Form Eyeglasses Order Form Universal Form Frames To See Form Estimate Form Optician Templates Fillable Fax Form Patient Notes Mailing Labels Card For Patients Thank You Letter


Insurance Information
Moda
Care Oregon
Pacific Source
Moda Commercial Auth Moda Medicare Auth
Care Oregon Online (External Link)
Pacific Source Auth Pacific Source Handbook
United Healthcare Auth
Providence Prior Auth
Atrio Prior Auth
United Healthcare Auth
Providence Prior Auth
Atrio Prio Auth
Health Net
Regence
Medicare
Health Net Prior Auth Health Net Non-Medicare Prior Auth
Regence Pre-Authorization
ABN Blank Medicare Form ABN Non-Medicare Form
Co-Management Forms
Forms
Co-Management Services Cataract 5 to 10 Day Post-Op Report Cataract 4 to 6 Week Post-Op Report Pre-Operative Referral Confirmation Pre-Operative Confirmation Post-Operative Confirmation


Employee Forms
Time Off Request Form Direct Deposit Form Clerical Skill Evaluation MCEC Overtime Authorization