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
