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Office (850) 942-2299 | Fax (850) 942-0322. OUTPATIENT CONSULTATION FORM. Date of request: Patient's Name: DOB: Address:

Southeastern Center for Infectious Diseases, P.A. Philbert J. Ford, M.D. Board Certified Infectious Diseases 2009 Miccosukee Road Tallahassee, FL 32308 Office (850) 942-2299 | Fax (850) 942-0322

OUTPATIENT CONSULTATION FORM Date of request: _____________________________________________________________________ Patient’s Name: ______________________________ DOB: __________________________________ Address: ____________________________________________________________________________ ___________________________________________________________________________________ Home Phone: ______________________________ Work Phone: ______________________________ Cell / Other: ______________________________

Insurance Coverage: ______________________________ ID #: ________________________________ Authorization #: ________________________ # of visists: ______________ Exp Date: ______________ If patient is a client of Big Bend Cares, case worker’s name: ____________________________________ If Big Bend Cares is financially responsible, purchase order number (PO#): ________________________

Physician requesting consultation: ______________________________________________________ Physician signature: _________________________________________________________________ Contact person in your office: __________________________________________________________ Phone: ______________________________________ Fax: ___________________________________ Patient’s primary care physician: ________________________________________________________ Reason for appointment? ______________________________________________________________

**** PLEASE FAX ALL PERTINENT MEDICAL RECORDS WITH THIS COMPLETED FORM. IF THE PATIENT’S INSURANCE CARRIER REQUIRES THEM TO HAVE AUTHORIZATION, PLEASE ENSURE THAT NUMBER IS LOCATED ABOVE. WE WILL CONTACT THE PATIENT DIRECTLY TO SCHEDULE AN APPOINTMENT. PLEASE FEEL FREE TO CONTACT US WITH ANY QUESTIONS. THANK YOU! ****