HP-0193 07-2020
Diabetes Eye Exam Consultation
Sanford Health Plan is concerned with ensuring the continuity and coordination of care of our members with
diabetes. In order to improve the lines of communication between our eye care professionals and our
member’s primary diabetes care provider, we recommend that your clinic utilize this form in providing your
patient’s primary diabetes care provider with information related to their diabetic eye exams.
Diabetes Care Provider Information
Clinic Name: Provider Name:
Patient Name Patient DOB:
Street Address:
City: State: Zip:
Phone Number: Fax Number:
Date Seen:
Dilated Eye Exam: Yes No
No diabetic retinopathy
Early diabetic retinopathy
Pre-proliferative disease
Proliferative retinopathy
Laser therapy in my office is scheduled for
Referral for therapy made to
Other Findings:
Macular edema
Other eye disease
Follow-up Planned:
Will schedule for annual dilated eye exam
Will reschedule re-check in 6 months
Will reschedule re-check in 3-6 months
Eye Care Provider
I authorize release of this information to my primary diabetes care provider.
(Patient Signature)
Eye Exam Clinical Findings and Recommendations
click to sign
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