Thank you for considering Circle City Neuro-Ophthalmology for your patient’s neuro-ophthalmology needs! You may initiate a referral to us using one of the following methods:
You may call our office at (317) 805.2240 to initiate the referral. You will need to provide the following information at the time of the phone call:
- Referring provider’s name and degree
- Referring provider’s National Provider Identification (NPI) number
- Your practice address
- Your practice phone number
- Your practice fax number
- Patient’s name
- Patient’s date of birth
- Patient’s Social Security number (SSN)
- Patient’s phone number(s)
- Patient’s e-mail address (if known)
- Reason for referral and onset of condition
- Patient’s primary and secondary insurance information, including policy ID #, group #, policyholder’s name and date of birth, authorization/pre-certification number, and authorized dates of service
You may also fax a referral form to (317) 527.4708. Click the button on the right to download the referral form!
You may also fill out an online form on the Midwest Eye Institute website that will send a secure e-mail of the referral information to us. Click the button on the right to go to the online form!