MARCUS A. EAST, M.D.
ADAM T. SHUPE, O.D.
RYAN W. LAPOUR, M.D.
PATRICK KWONG, O.D.
Insurance Referral Request Form
NEW REFERRAL?
YES
NO
SURGERY?
YES
NO
Referral Request By
Patient Name
DOB
Insurance
AARP Medicare Complete-Salem Clinic
ATRIO Silver
ATRIO Gold
CARE or MED Advantage
CHAMP VA
CIGNA Healthcare
CIGNA Vision
DMAP - Division of Med Assistance Prg
OHP - Oregon Health Plan
WVCH - Willamete Valley Comm Health
EBMS
EYEMED BENEFIT
FAMILY CARE
HEALTHNET Med Advantage
HEALTHNET Vision
KAISER Added Choice
LIBERTY MUTUAL INSURANCE
LIFEWISE Oregon
MET LIFE Insurance
MODA
PACIFIC SOURCE Health Plans
PAN-AMERICAN Life Ins
PROVIDENCE Health Plan
PROVIDENCE Medicare Advantage
PROVIDENCE Medicare Extra
PROVIDENCE PEBB
PROVIDENCE PEBB Choice Medical Home
REGENCE (BCBS) Blue Advantage - HMO
REGENCE (BCBS) Med Advantage - HMO
SAIF Corporation (work related)
SAMARITAN
SHASTA Administrative Services
STATE FARM MVA
SUPERIOR Vision (regular)
TRICARE for Life
TRILLIUM OHP
UNITED HEALTHCARE
VETERANS CHOICE
VSP BENEFIT
ID #
PCP/Clinic
Phone #
Fax #
MARCUS A. EAST, M.D.
ADAM T. SHUPE, O.D.
RYAN W. LAPOUR, M.D.
PATRICK KWONG, O.D.
Add Visits
Total of
Ref #
From:
To:
Diagnosis Code
REFERRAL START DATE:
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31
/
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2019
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RETRO
Notes:
655 Medical Center Dr NE
|
Salem, Oregon 97301
|
503.581.5287
|
Fax 503.386.1377
|
mceyeclinic.com
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