Appointment Request - HIE Networks

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Phone- 850-877-0101 | Fax 850-877-2750 | www.tallyent.com. Appointment Request. Please note if your patient needs to be
TALLAHASSEE EAR, NOSE & THROAT – HEAD & NECK SURGERY, P.A. DUNCAN S. POSTMA, M.D., F.A.C.S., SPENCER E. GILLIEON, M.D., ADRIAN P. ROBERTS, M.D., MARIE O. BECKER, M.D., F.A.C.S., ROBERT M. SNIDER, M.D., JOSEPH C. SOTO, M.D., TRICIA SKINNER, A.R.N.P. Phone- 850-877-0101 | Fax 850-877-2750 | www.tallyent.com

Appointment Request

Please note if your patient needs to be seen on an URGENT basis call our office at 877-0101. Today’s Date: ___________________________ Referring Doctor: _______________________________ Reason for Visit: _______________________________________________________________________ Appointment: (Please Mark One)

Next 3-5 days Next Available (usually 2 weeks for a return; 4 weeks for a new patient)

PATIENT INFORMATION: Patient Name: _______________________________ Patient DOB: ______________________________ Home Phone: ______________________________ Work Phone: _______________________________ Home Address: ________________________________________________________________________ City: ___________________________________ State: __________________ Zip: __________________ Primary Insurance Name: _______________________________________________________________ Policy or ID Number: __________________________ Authorization #: ___________________________ Medical Records-Please fax over to our office. Have they been faxed?

Yes or

No

Yes or

No

(please check one)

VISTA Insurance Authorization. Has the authorization been faxed to us?

(please check one)

CHP Insurance Authorization. Has the authorization been submitted to CHP?

Yes or

No

(please check one)



If we have questions regarding this referral, whom should we contact in your office?

______________________________ Name

_____________________ Phone Number

_____________________ Fax Number

TENT has scheduled your patient with: _____________________________________________________ Appt Date: ___________________________________

Time: ___________________________

Location:

1405 Centerville Road – Suite 5400

2626 Care Drive – Suite 208

Patient Contacted:

Talked to Pt

LM for patient

Not able to contact

If this is NOT your patient, please return fax to 850-877-2750