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:

Phone

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

Fax

Online Form