ASGNY Surgery Forms - April 2024 Update

Name

First NameLast Name
Today's Date*

MonthDayYear
Date
Hour Minutes
Date of birth

MonthDayYear
Date
Type of Surgery
CPT = PROCEDURE CODE
Diagnosis
ICD 10 = DIAGNOSIS CODES
Date of Surgery

MonthDayYear
Date
POST OP Date

MonthDayYear
Date
Which eye

RightLeft
Which eye
Type a question

Nuclear ScleroticGlaucoma
The Post-Operative appointment is scheduled at

OCNYNYO Washington HeightsNYO Jackson Heights
Requesting Surgeon
Address

Street Address

Street Address Line 2

CityState

Zip
Home Phone
Cell Phone
Business Phone
Next of Kin
Relationship
Phone
Insurance Co. Name
Policy #
Group #
Co Pay
Secondary Insurance
Policy #
Group #
Co Pay
Address of Responsible Person
Witness Full Signature
This Form Completed by

Clear
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

Clear
Glare Right Eye
Glare Left Eye
IOP OD
IOP OS
C/D Ratio OU
Should be Empty: