Referring Providers

Referral Form and Fax Checklist

Send the patient’s referral, insurance and authorization information, and relevant clinical records using your office’s referral form or the spineTECH form provided below.

Complete information helps our team review the referral, identify an appropriate starting point, and reduce scheduling delays.

How to Submit a Referral

  1. 1Include the patient’s current insurance information and any required referral or authorization.
  2. 2Attach relevant clinical notes, imaging reports, test results, and prior treatment records.
  3. 3Complete our Patient Referral Form or include your office’s referral form.
  4. 4The form should clearly identify the patient, reason for referral, clinical concern, and referring provider.
  5. 5Fax the completed referral packet using the approved spineTECH referral fax number (409) 898-0177.
  6. 6Keep the fax confirmation for your records.

spineTECH Patient Referral Form

Optional Form

Don’t have a referral form of your own? Use the spineTECH Patient Referral Form to provide the patient, insurance, authorization, and clinical information needed for review. Your office’s referral form is also accepted as long as the necessary information and supporting records are included.

Open Referral FormDownload PDF

Include When Applicable

  • Patient demographics and contact information
  • Insurance card and member information
  • Required referral or prior authorization
  • Reason for referral and current symptoms
  • Relevant diagnosis codes
  • Recent clinical notes
  • Imaging reports and access instructions
  • EMG, nerve-testing, laboratory, therapy, operative, hospital, or emergency records
  • Prior treatment and response
  • Workers’ compensation, VA, HMO, or other payer documentation