1500 South 48th Street, Suite 506, Lincoln, Nebraska 68506, United States
Phone: (402) 489-1110 Fax: (402) 489-8492
Patient referral
Need to refer a patient to our office:
Referral Process:
Referral Request Form
*PLEASE FILL OUT COMPLETELY AND SEND ALL REQUESTED RECORDS TO ENSURE A QUICK REFERRAL PROCESS FOR THE PATIENT*
Please indicate if this is and URGENT referral
Patient Name: ______________________________________________
Date of Birth: ______________
Patient Phone Number/Contact Information:_________________________
Reason For Referral:___________________________________________
_
Referring Provider:____________________________________________
Referring Provider fax/phone:_____________________________________
Please fax all requested information to 402-489-8492 or 402-489-1545
*Completed referral form
*Recent and pertinent office visit notes
*Labs relating to the referral diagnosis
*Diagnostic imaging reports relating to referral diagnosis
*Current medication list and allergies
*Demographic information with insurance card
Once all the above is received, the referral will be
reviewed and we will call the patient to schedule