Parkhurst NuVision Doctor Referral Portal

Please use this form for new patients. Click here to send us pre/post-op notes.

Appointment Type*

Patient Name*

First Last

Phone*

Patient Birthdate*

Patient Email (Optional)

Upload Patient Paperwork

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Max. file size: 100 MB.

Referring Doctor*

Referring Location*

Referring Doctor Email*

Additional Comments*

Terms of Use*

I Agree To the Terms of Use*

Communications through our website or via email are not encrypted and are not necessarily secure. Use of the Internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use. The top priority of Refractive Surgery & Diagnostic Center, P.L.L.C., NuVision Same Day Procedure Center LLC, and Dr. Gregory Parkhurst (collectively “PNV”) and you ("Referring Doctor") has always been and will always be to optimize patient care, not to provide revenue for PNV or for Referring Doctor or for anyone else. PNV’s and Referring Doctor’s true customer has always been and will always be the patient, not PNV or Referring Doctor. All of Referring Doctor’s referrals have always been and will always be based on Referring Doctor’s best medical judgment, rather than on any potential for financial gain. PNV’s treatment of patients referred by Referring Doctor has always been and will always be based on PNV’s best medical judgment, rather than on any potential for financial gain. PNV has never paid nor offered and never will pay nor offer Referring Doctor any remuneration or anything of value in any form or manner whatsoever for the purpose of inducing Referring Doctor to refer patients to PNV. Referring Doctor has never had and will never have any written or unwritten agreements or understandings to co-manage patients with PNV. PNV has never provided and never will provide routine or automatic co-management of patients with Referring Doctor as a fait accompli. PNV has never promised, guaranteed, implied, or suggested that referred patients will go back to Referring Doctor for post-op care. Referred patients have always been and always will be permitted to receive their post-surgical care from PNV or from Referring Doctor or from another eye doctor as determined on a case-by-case basis exclusively for the health, convenience, and preference of the individual patient. Referring Doctor has never upsold and will never upsell any patients referred to PNV to receive premium IOL’s (as opposed to standard IOL’s) or to receive laser treatments in conjunction with cataract surgery. Referring Doctor has never charged and will never charge amounts for post-op care in excess of its fair market value. Referring Doctor has never charged and will never charge additional amounts for post-op care for premium IOL’s or for laser treatments performed in conjunction with cataract surgery or for any other types of surgeries unless such additional amounts equal the fair market value of the additional work actually performed for such post-op care after it has been completed. If the amount paid to Referring Doctor for a patient’s post-op care exceeds the fair market value of the post-op care actually performed by Referring Doctor after such post-op care has been completed, then Referring Doctor agrees to refund such excess amount to the patient, and Referring Doctor agrees to be the one responsible for monitoring and correcting such overpayments. All referrals that Referring Doctor has ever made or ever will make to PNV are in full compliance with the Antikickback Statute (42 U.S.C. § 1320a-7b(b)) and the Stark Laws (42 U.S.C. §1395nn, §1396b(s) and 42 C.F.R. §§411.350 - .389) and all other laws, rules, and regulations. All of the foregoing statements in these Terms of Use are acknowledged, agreed to, and affirmatively stated and represented by Referring Doctor. PNV is relying on all the foregoing statements in these Terms of Use to the extent that it accepts referrals from Referring Doctor.

Phone

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