consultation request - HIE Networks

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(850) 877-8174 | Fax (850) 877-5636 (850) 877-8174 | Fax (850) 877-5636 ... Please advise patient that any copay/co-insu
TOC Marianna Office

Tallahassee Orthopedic Clinic

3051 6th Street

3334 Capital Medical Blvd, Suite 400

Marianna, FL 32446

P.O. Box 13100 | Tallahassee, FL 32317

850-526-3236 | 850-526-4060

(850) 877-8174 | Fax (850) 877-5636

TOC POB Office 1401 Centerville Rd, Suite 710

TOC Bainbridge Office 603 S. Wheat Avenue, Suite 800 Bainbridge, GA 39819

Tallahassee, FL 32308 (850) 877-8174 | Fax (850) 877-5636

229.246.3608 | 229-246-1635

CONSULTATION REQUEST Patient’s Name: _______________________________________________________________ Date of Birth: ______________ SS #: _____________________ (we must have SS # to schedule appointment) Address: _______________________________________________________________ Home Ph #: __________________ Work Ph #: __________________ Cell #: _____________________ Medical Reason for Appointment: ________________________________________________________

Has patient had x-rays, MRI, ect.? Yes No (Patient must bring x-ray’s, MRI, ect. with them to the appointment) Was patient involved in an accident or injury?

Yes

No

MVA

W/Comp

If “Yes”, Date of Injury/Accident: _____________________________________

Other

*** Please advise patient that any copay/co-insurance is due at the time services are rendered *** Insurance Primary: ___________________________ Secondary: ___________________________ *** Patient must bring insurance card(s) and a picture I.D. at the time of the appointment *** Physician Requesting Consult: ________________________________________________________ Office Phone #: ___________________________ Office Fax #: ___________________________ I am requesting that Tallahassee Orthopedic Clinic or its affiliated satellite offices perform a consultation on the above referenced patient for the medical problem indicated. __________________________________________

Physician’s Signature

______________________________

Date

Appointment Information Date: ___________________________ Time: ___________________________ Location: __________________________________ Provider: __________________________________ *** Please note all information must be completed and signed before an appointment will be scheduled *** *** We will return this fax to you with an appointment date and time ASAP ***