Referral Request Form printable pdf download

Referral Request Form

Sergiy Nesterenko, M.D.

Orthopaedic Spine Surgeon

2412 50th Street

Lubbock, TX 79412

Ph: 806-744-7223 ext 4180

Fax: 806-740-3382

Referral request form

☐ Check here if you prefer an appointment at Lamesa office (once a month)

☐ Telemedicine

Please Complete All Information (Please Print):

Referring provider_______________________________________________________________________

Street address____________________________________ City ________________ State_______ Zip _________

Phone number ____________________________ Fax number_________________________________

Contact name within provider office _________________________________ Date of referral _________________

Patient Information (Please Print):

First name _____________________ Middle: _____ Last name_____________________ DOB: _______________

Address_______________________________________ City_____________________ State_____ Zip _________

Home phone: _________________________ Cell: ___________________________

Diagnosis / Reason for referral: ________________________________________________________________

_______________________________________________________________________________________________

Patient’s insurance: __________________________________________________________________________

**We accept most insurances including Worker’s Compensation (requires case review).

We will notify you if we are unable to see the patient due to insurance. We do not see Motor Vehicle Accident related

cases with active litigation and two insurance plans: BCBS HMO Blue Advantage and UMC Team Choice.

There is no imaging requirement for the new patients, but in order to schedule them we need to have the following:

☐ most recent clinic note

☐ completed new patient questionnaire

☐ previous studies (both images and radiology reports)

Thank you for your referral and the opportunity to assist in the care of your patients.

Referral Request Form