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RETINAL EYE EXAM
TRACKING FORM

Internal Medicine Physicians thanks you for taking part in the care of our patients.  As a part of our quality reporting, we track retinal eye exams for our patients with diabetes as well as screening for glaucoma.  Please complete the form below indicating exam date, whether or not this patient has the presence of diabetic retinopathy and/or glaucoma, as well as the specific ICD-10 code(s) you are using.  When you have completed the form, please fax it back to us at the number listed below.  Thank you for your time and again, thank you for being a part of the care team. 

Presence of Diabetic Retinopathy
Presence of Glaucoma
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