MARCUS A. EAST, M.D.
JOHN G. DODD, D.O.
RYAN W. LAPOUR, M.D.
ADAM T. SHUPE, O.D.
Inbound Patient Referral
Thank you for choosing Medical Center Eye Clinic.
We look forward to partnering with you in your
patient’s eye health care!
Attn:   INCOMING REFERRAL
Please fax form to:
(503) 386-1377
Date:
REFERRING PROVIDER INFORMATION
Referral Submitted by:
Clinic Name:
Ordering Provider:  
Address:
City:  
State:  
Zip:  
PCP / Clinic:
Phone #:  
Fax #:  

PATIENT INFORMATION        
Patient Name:
Birthdate:  
Address:
City:  
State:  
Zip:  

INSURANCE / AUTHORIZATION INFORMATION
Date Ordered:
Auth # (if Required):  
Insurance Carrier:
Policy #:  
Primay / Billing Diagnosis:
ICD-10 Code(s):

ADDITIONAL INFORMATION
Clinic Information / Comments
655 Medical Center Dr. NE
Salem, Oregon 97301
503.581.5287
Fax 503.386.1377
mceyeclinic.com