Patient Consent Form for
Glaucoma Co-Management
Patient
Name:__________________________,____________________Date____________
( Print or type) Last
name
First
I have been
diagnosed with glaucoma, an eye disease that requires careful
management. At this time my Optometrist is in the process of being
credentialed to treat glaucoma. This process will have my optometrist
and ophthalmologist work together to provide me the appropriate care to
maintain good eye health.
I agree to have my
Optometrist, ____________________, Doctor of Optometry, and an
Ophthalmologist, __________________, MD, jointly evaluate and manage my
glaucoma for 18 months. According to NH State Law, RSA 327:6-c, II, the
co-management of my condition by my optometrist consists of the
following:
1. After initial examination and
diagnosis, my optometrist will develop a treatment plan and goal target
pressure.
2. My
optometrist will refer me to an ophthalmologist for a consultation.
3. The ophthalmologist will examine
me and review my optometrist’s findings, diagnosis and proposed
treatment plan.
4. The ophthalmologist, my
optometrist and I will agree on a written treatment plan. This treatment
plan may include follow-up visits with both practitioners.
5. I understand that as part of the
credentialing process, my optometrist shall complete a form that will be
submitted to the Joint Pharmaceutical Formulary and Credentialing
Committee for review of my treatment. My name will NOT appear on any
documentation that my doctors submit.
6.
During the co-management period my
optometrist will refer me within 30 days to the co-
managing ophthalmologist if
testing indicates that my glaucoma is not adequately controlled.
This would include such
indicators as not reaching the target pressure within 90
days; the need
to use more than two glaucoma
medications; progression of optic
nerve damage; worsening
field of vision or additional
glaucoma complications.
I have read this
form and agree to follow and comply with the treatment plan, as
prescribed.
I authorize the
above named doctors, to share my clinical information and to report it
anonymously to the committee.
Finally, I
understand that it is my right to change my doctor (optometrist and or/
ophthalmologist) at any time or to end this co-management at any time.
_____________________________________
_____________________
(Patient
signature)
Date
We have agreed to
the glaucoma co-management of the above named patient.
______________________________________________ ____________
_______________________________________________
____________
Optometrist
Signature Date
Ophthalmologist Signature
Date
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