Taylor Station Specialist Request

Taylor Station Specialist Request

Taylor Station Surgical Center - (614) 751-4466
Please fill out as much information as possible and you will receive a response within one business day.
1. Your Name:*

First NameLast Name
2. Health Insurance Coverage*
3. Your Family Doctor:*

First NameLast Name
4. Family Doctor Phone Number:

Area CodePhone Number
5. Email Address*
example@example.com
6. Your Contact Number where we can call you or leave a message:*

Area CodePhone Number
7. TSSC Doctors and Specialization
8. Reason for specialist:*
Taylor Station Surgical Center referral service makes referrals only to the Physician-Owners of Taylor Station. The Physicians receiving referrals from Taylor Station’s referral service do not pay any fees to participate in this referral service and that the referral service costs are expenses of Taylor Station Surgical Center. The referral request will be sent to the Specialty Office, where members of the office will refer the patient to either the first available Physician-Owner or the Physician-Owner that is available to meet at the patient’s requested time and day. If multiple Physician-Owners are available at the requested time and day, the office will refer the patient to the next Physician on a rotating list. Taylor Station has a relationship with the physicians receiving referrals in that these physicians are also owners of TSSC. All Physician-Owners of Taylor Station Surgical Center may participate in this referral service until they are no longer an owner of Taylor Station Surgical Center.

Taylor Station Surgical Center does not contract with Caresource or Medicaid.

I understand the disclosure statement noted above and agree to proceed with my request for referral services.
Digital Signature:*

First NameLast Name
Date:*

MonthDayYear
Date
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