Eye Examination Report for Diabetes

Developed by the New York Diabetes Coalition

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Frequently Asked Questions

What is the purpose of this form?
The American Diabetes Association recommends patients with diabetes receive annual retinal examinations. The purpose of this form is to facilitate communication between eye care and primary care professionals (PCP) and with patients about diabetes related eye problems.

Who is the New York Diabetes Coalition (NYDC)?
The NYDC is a collaboration of health plans, professional medical societies, state and county departments of health, community based organizations, quality improvement agencies, health care providers and diabetes care vendors. Its mission is to improve the health of people who live with diabetes by delivering tools and technology to help professionals and patients manage diabetes care.

Where can I get this form?
The New York Diabetes Coalition,* http://www.nydc.org, New York State (NYS) Department of Health Diabetes Prevention and Control Program, www.health.state.ny.us/diseases/conditions/diabetes/adult_tool_kit.htm,* NYS Ophthalmologic Society, www.nysos.com, NYS Optometric Association, www.nysoa.org, and IPRO, www.ipro.org. *Hard copies may also be ordered from these sites.

Why should I use this form?
This form can help to improve the coordination of care among different health professionals caring for a patient with diabetes, and meets the reporting and documentation requirements for certain pay for performance programs and mandatory quality reporting, such as the Center for Medicaid and Medicare’s (CMS) Physician Quality Reporting Initiative and Health Plan Employer Data and Information Set (HEDIS).

Who has approved or reviewed this form?
Approved by the NYS Ophthalmological Society (6/14/07), the NYS Optometric Association (6/13/07) and the National Committee for Quality Assurance (NCQA) (6/5/07). Reviewed by the American Diabetes Association.

How is this form used?
The eye care professional may get this form from the patient, the primary care physician or themselves. Once it is completed, it should be faxed or mailed back to the primary care physician, included in the patient’s chart and a copy shared with the patient.

Can the form be altered?
Changes to the form, such as adding your own logo, can be done with permission from the NYDC. See contact information.

Why is this form translated into Spanish?
It is important for persons with diabetes to be engaged with their health care providers to manage their own health care needs. By translating this form into Spanish, this growing population of patients with diabetes will better understand the importance of an annual eye exam and be able to become more active in their own care.

This form was developed by the New York Diabetes Coalition (www.nydc.org) in collaboration with eye care professionals and the New York State Department of Health Diabetes Prevention and Control Program. Contact NYDC at 518-432-1382 or info@nydc.org.