ASGNY Surgery Forms - April 2024 Update

Name

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour Minutes
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Surgery
CPT = PROCEDURE CODE
Diagnosis
ICD 10 = DIAGNOSIS CODES
Date of Surgery

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
POST OP Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Which eye
Which eye
Type a question
The Post-Operative appointment is scheduled at
Requesting Surgeon
Address

Street Address

Street Address Line 2

CityState

Zip
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Business Phone
Format: (000) 000-0000.
Next of Kin
Relationship
Phone
Format: (000) 000-0000.
Insurance Co. Name
Policy #
Group #
Co Pay
Secondary Insurance
Policy #
Group #
Co Pay
Address of Responsible Person
Witness Full Signature
This Form Completed by
CONSENT FOR SURGICAL PROCEDURES
Explain the nature of the surgery to the patient using plain language including

1. Risks of procedure

2. Benefits of procedure

3. Alternatives of the procedure

After all of the patients questions are answered and they accept the risks then they can sign the form.

They are also consenting to

1. Surgery

2. Right for Surgery Center to call them and leave messages

3. Release of Medical Information to process the claim
Patient Signature
Glare Right Eye
Glare Left Eye
IOP OD
IOP OS
C/D Ratio OU
Should be Empty: