Scheduling: (813) 24- TOWER (8-6937)
Medical Records: (813) 875-7424
Billing: (813) 253-2721 ext. 0
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* Indicates Required Field
SCHEDULING (813) 874-3177 FAX (813) 879-1809
Very Important:
Fax All Supporting Office Notes, Applicable Test Results & Prescriptions
Call Patient to Schedule Appointment
Only Assign Appointment and Return Appt. Confirmation Back to Our Office (Referring office will notify patient of their appointment)
Obtain Authorization
 
Ordering Physician:*
 
Patient's First Name:*
Patient's Middle Initial:
Patient's Last Name:*
Date of Birth:* - -
Social Security Number: - -
Home Phone:* - -
Alternate Phone: - -
Allergies: NKA
 
Insurance Company Name:
Insurance ID#:
Authorization or Pre-Cert #:
 
Exam(s) Ordered:*
CONTRAST
1. With
Without
With and Without

2. With
Without
With and Without

3. With
Without
With and Without
Diagnosis or Signs/Symptoms:* 1.
2.
3.
Exam Prescription:
Office Clinicals:
Comments:
 
 
 
Very Important:
Fax All Supporting Office Notes, Applicable Test Results & Prescriptions

Tower must have the exam authorization by 3 pm
the day prior to patient's appointment.

To report authorizations or if you have authorization questions
call the Tower Auth. Dept. at (813) 594-5920.


 
 



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