Gastroenterology Specialties, P.C. & Lincoln Endoscopy Referring Office

For Referring Offices Only.

Please fill out the Referral Form below.

Referring office*
Referring Provider*
Referring office phone number*
Referral Reason*
- Office consultation
- Screening Colonoscopy (No symptoms/no history of polyps) - PLEASE SEND MOST RECENT VISIT NOTE FOR INSURANCE PRIOR AUTH REQUEST
- Diagnostic Colonoscopy (patient with symptoms)
- EGD (patient with symptoms)
- Specialty Endoscopy (EUS or ERCP)
Symptoms for Consultation*
Symptoms for Diagnostic Colonoscopy*
Symptoms for EGD*
Indications for EUS or ERCP*

Please call Susan S at 402-465-4545 for urgent cases
Patient Name*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Patient Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient preferred language*
Interpreter needed?*
- YES
- NO
Patient Cell Phone*
Other Phone
Insurance Carrier*
Plan ID #*
Group Name*
Group #*
Optional records upload
Accepted file types: pdf, Max. file size: 64 MB.
You may also fax records to 402-465-9011
Comments
This field is for validation purposes and should be left unchanged.

Referring Office