Records Review Service Request Form

Records Review Service Request Form

We currently offer telephone and video conferencing two Friday’s a month. Our email exchanges will be at any time. When completing this Records Review Service Request Form, please indicate your preferred method of communication with our staff, who will assist you in preparing for your telephone and/or video conference with the physician. Our staff will provide you a date and time along with call in and/or video conference instructions for your conference with the physician once you have had an opportunity to review and accept our estimated cost of service.

Please indicate the service(s) you would like to utilize for your Records Review appointment.

 

Records Review Service Request Form

 

Patient Name

 

Patient Address

 

Patient Contact

 

Physician - Provider References

 

Primary Care Physician

 

Referring Physician

 

Neurologist

 

Cardiologist

 

Audiologist

 

Other Provider

 

Guarantor (Responsible Party) Demographics

 

Guarantor Contact Information

 

Disclaimer Statement for Appointment Request or Referral

  • Thank you for using the online form to request an appointment or refer a patient to Tampa Bay Hearing and Balance Center a division of Select Physicians Alliance. The Tampa Bay Hearing and Balance Center has provided this form to allow you to begin the new patient registration process from the comfort of your home or office. The information that you submit will be transmitted securely over the Internet. Use of this web site is subject to our Terms Of Use: www.tampabayhearing.com/disclaimer

    By clicking "Submit":

    You assert that you and/or your office has obtained the necessary signed release form(s) from your patient to submit/refer them to Tampa Bay Hearing and Balance Center. Our scheduling specialists will contact your patient to obtain additional information and to schedule an appointment. A patient relationship cannot be established until the patient is seen, in person, at Tampa Bay Hearing and Balance Center by Tampa Bay Hearing and Balance Center's medical staff.

    You agree to the terms of this Disclaimer. If you do not agree to the terms of this Disclaimer, you may call Tampa Bay Hearing and Balance Center at (813) 315-4327 to begin the appointment registration / referral process. We look forward to seeing your patient at the Tampa Bay Hearing and Balance Center.

    Thank you for your referral.

    Please click SUBMIT once and allow a few seconds for the form to be sent. You will be taken to a confirmation page with further instruction once the form has been submitted.
 

Verification