Bascom Palmer Eye Institute



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Thank you for your interest in Bascom Palmer Eye Institute at the University of Miami School of Medicine.

The Appointments Office is open Monday through Friday from 8 a.m. to 6 p.m. EST. For your convenience, you may initiate the appointment process by phone at 305-243-2020 or 888-845-0002, or by completing the following form.

This secure form uses SSL technology to ensure the privacy of the personal information you are submitting.

Thank you.

Please Note: If you are experiencing symptoms that are urgent in nature, please contact your primary care physician or visit the nearest urgent care facility.

Items marked with a red asterisk are mandatory.


First Name* Middle Name Last Name*
 
Date of Birth*  
 
 
Gender* Male Female  
 
Street Address*
City* State*  
 
     
Zip Code* Country*  
 
     
Daytime Phone*
(with Area Code)
Evening Phone*
(with Area Code)
 
 
     
Fax
(with Area Code)
Email Address*  
 
     
Type of Service Requested*  
     
Specify if Other    
 
     
Specify Symptoms*  
     
Desired Date for Appointment* Physician You Would Like to See Preferred Bascom Palmer Location
 
The State of Florida Agency for Healthcare Administration requires that we obtain and report the race of individuals for which we provide care. We are not allowed to arbitrarily assign a race code; it needs to be self designated. Please select one option:
Race*
 
Complete Name of Your Primary Care Physician (PCP)  
 
     
Street Address of PCP    
     
City State  
 
     
Zip Code Country  
 
     
Office Phone
(with Area Code)
Office Fax
(with Area Code)
 
 
     
Are you Currently Receiving Eye Care? Yes No
     
If Yes, Please Specify What Type of Treatment
     
You will be contacted in order to review insurance coverage and obtain additional demographic information. Medical and financial eligibility need to be established prior to confirming an appointment. To expedite this verification, you may provide us with the following optional information.
     
Insurer    
 
     
Insurance Number / Policy / Member ID
   
     
Customer Service Phone Number
(with Area Code)
 
   
     
Name of Insured if Not Patient  
   
     
Date of Birth of Insured if Not Patient
   
     
Insured's Address    
     
Insured's Daytime Phone
(with Area Code)
Insured's Evening Phone
(with Area Code)
 
 
     
Is the Patient a HMO Subscriber? Yes No
  If Yes, Name and Policy/Group # of HMO  
   
  If No, Insurance Carrier Name and Phone  
   
     
Does the Patient Have Medicare? Yes No
  If Yes, Medicare Cert. #  
   
     
Does the Patient Have Medicaid? Yes No
  If Yes, Medicaid Cert. #  
   
     
If you would like to leave a further message for the Physician Referral Office, please type it here.
     

Information collected from this Web site or provided on any form you have submitted through the Web site is used only in conjunction with an expressed interest by the User in obtaining additional information about Bascom Palmer Eye Institute’s or the University of Miami’s physician practice or services. It does not create any type of relationship between the individual providing the information and Bascom Palmer Eye Institute at the University of Miami or any of its physicians. This information is not considered Protected Health Information (PHI) and will be used to contact you because you have requested to be contacted. In addition, information provided on the Web site or in any response to you is not and cannot be considered medical advice or treatment. Bascom Palmer Eye Institute at the University of Miami will not be liable for and you will release and hold them harmless from any claims and/or any direct, indirect, consequential, special, exemplary, or other damages arising therefrom. Please consult with your doctor for medical advice or treatment for any condition you may have. If you are experiencing a medical emergency, call 911 and/or go to the nearest emergency room.

I have read and agree to the above.

 

All referral forms will receive a phone or email response within one business day. The Appointments Office is open Monday through Friday from 8 a.m. to 6 p.m. Eastern Time. You can reach us at 305-243-2020 or 888-845-0002.

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