For Referring Provider Use Only
These forms are to be completed only by a medical professional or medical staff of a referring practice. If you are a patient, click here to request an appointment.
Online Referral Form:
Orthopedic Patient Referral Form
Neurosurgery/ Spine Patient Referral Form
Physician Direct Access Lines:
(402) 779-8680 - Orthopedic Direct Line
(402) 779-8681 - Neurosurgery & Spine Direct Line
REMINDER – please fax over the following for your patients to (402) 399-8455.
- Insurance Card
- Photo ID
- Co-pay (if applicable)
- Radiology Films/CD and reports
- MRI
- CT
- X-Rays