Continuity and Coordination of Care Program

MESVision's Patient Referral Guidelines and Requirements (Quality Improvement Policy and Procedures #03) require that our participating providers practice Continuity of Care, including referral to a medical specialist along with documentation of the process. In addition, we will be looking to see that the Coordination of Care indicates communication between eye care providers and the primary care physician of patients when indicated (e.g. Diabetic patients). Listed below are sample forms intended to guide your office in documenting necessary information needed by providers to demonstrate appropriate referrals and documentation.

Sample Patient History Form

Download this form to reference the MESVision standards for patient history records.

Sample Patient Exam Form

Download this form to reference the MESVision standards for patient exam charts.

Sample Patient Referral Form

Download this form to reference the MESVision standards for patient referrals to specialists.

Sample Diabetic Patient Evaluation Form

Download this form to reference the MESVision standards for Diabetic patient referrals to an eye care specialist.

Sample Referral Tracking Sheet

Download this form to reference the MESVision standards for referral tracking.

Other Forms

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