Clayton Eye Center - Referral Survey
We at Clayton Eye Center appreciate the opportunity to assist you in the management of your patients. By completing this form, we can better serve your patients & accommodate your preferences.

Cheryl Fincher, COA
Patient/Doctor Liaison

Clayton Eye Center
1000 Corporate Center Drive, Morrow, GA 30260
Cell: 770-833-3999 | Office: 770-968-8888 ext: 233 | Direct fax: 770-960-2475
cherylfincher@claytoneye.net
www.claytoneyecenter.com

Practice
Practice Name *
Your answer
Is this equipment available in your office?
Yes
No
OCT
Visual Field
Topo
Provider
We strive to accommodate the preferences of each individual provider.

**If there are multiple providers at this practice, please complete this form once for each.**
After you submit the form, there will be an option to submit another response.

Provider's Name
Your answer
What times & days does this provider work at this practice?
Your answer
Does this provider prefer to treat these conditions?
Yes
No
Glaucoma
Macular Degeneration
Diabetic Eye Disease
How does this provider prefer to participate in cataract patient care for our most common MEDICARE insurers?
Co-Manage
Return for Refraction
Return for Annual Visits
Call Me
Medicare (Cahaba/Palmetto)
Aetna Medicare
Cigna Healthspring Medicare
Humana Gold Choice Medicare
UHC Medicare Advantage
UHC Care Improvement Plus
Wellcare Medicare
How does this provider prefer to participate in cataract patient care for our most common PRIVATE insurers?
Co-Manage
Return for Refraction
Return for Annual Visits
Call Me
Aetna
Cigna
Humana
UHC
BCBS Blue Card
BCBS of Georgia
BCBS FEP
Other Information
Can you provide a list of the insurance plans you accept?
We appreciate this in any format you prefer: typed or copied into the space below; faxed to us at 770-960-2475; or emailed to cherylfincher@claytoneye.net.
Your answer
Additional Notes
Is there any additional information or comments you would like to add?
Your answer
Submit
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