Referral Request Form

Referral Request Form

Welcome to Tampa Bay Hearing & Balance Center, a division of Select Physicians Alliance. We invite you to use this secure online form to refer your patient to our practice. Fields marked with and red * are required. Please complete as much of the form as possible. We are also available to help by phone (813) 315-4327 and by fax (813) 315-4329. Thank you for trusting us with the care of your patient.

 

Referring Provider Information

 

Office Contact

 

Appointment Information

 

Previous Hearing Test

 

Patient Name

 

Patient Gender

 

Patient Contact

 

Patient Address

 

Primary Insurance Information

 

Secondary Insurance Information (click to add)

 

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.
 

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