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Physician Application - Questionaire

IMPORTANT: Please fill out ALL information. We use this information to train our operators how to reach you. We can only be as good as the information given to us. All information is confidential, and numbers will NEVER be given out to callers unless we are instructed to do so.

Complete form fully, print, and fax or mail all forms to the address below.
Thank You

  
•
 Physician Name

 
•
 Pager Number
Digital or Alpha

 
•
 Home Number  
• Cell Number  
• Additional numbers the service may be using to contact Dr.  

How would you like us to handle the following emergency situations?


  
• Emergency medication calls:  
• Routine/Maintenance Medication calls:  
•

 Refills:  
•

 Employees calling in:  
•

 Calls from Outside Labs (Labcorp, Qwest):  
•

 Surgery Cancellations (If Surgeon):  
• What hospitals do you work out of?  
•

 Will you accept Dr. to Dr. calls when off call?  
•

 Will you accept personal calls when off call?  

How would you like us to contact you?
(Example: Page me 7am-10pm. Call Home 10pm - 7am and Patch callers)
It is VERY important this information is detailed so we won't be calling you at home in the middle of the night if you want to be paged, or paged at night if you wan't to be called at home.

  

What information would you like us to secure from your Patients?
 
• Caller Name:  
• Patient Name:  
• Phone Nmuber:  
• Age:  
• DOB:  
• Nature of call:  
• Other:  
• What Doctors do you share call with & how do we reach them?  
• How does your after hours On-Call work? (Examples: You take calls for yourself always, and will check out when off: OR You and the other Doctors in your office rotate .... etc.)
 

Consults and Room Notes:
It is Speed-E'z Exchange policy to contact Doctors for consults and room notes from 7am-10pm. Any consult or room note that comes in after 10pm will be held and sent to the physician at 7am the next morning. If you would like to be contacted for this information in a different manner, please state below:

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All of us at Speed-E'z Physician Exchange want to welcome you to our answering service and want you to know that we always strive to do our best for you and your patients.

JoAnn Browne, R.N. - Owner

  
 

Please check your form for accuracy and mail or fax it to:

Speed-E'z Exchange, Inc.
The Park on Medical
4115 Medical Drive, Suite 205
San Antonio, TX 78229

Fax: 210-576-5496