For Providers

To facilitate the scheduling of surgeries, after electronically completing the form below, please provide a copy of the patient’s current path report, demographics sheet and insurance information. This information can be faxed to us at 817.759.9808.

Click here to download PDF Referral Form

    Full Name of Patient (required)

    Name of Referring Provider (required)

    Phone Number of Patient (required)

    Phone Number of Referring Provider (required)

    Email Address of Patient (required)

    Email Address of Referring Provider (required)

    Insurance Accepted

    • Aetna
    • Beech Street
    • Blue Cross Blue Shield
    • Care Improvement Plus
    • Care N Care
    • Cigna
    • Coventry
    • Galaxy Healthcare
    • HealthSmart
    • HMO Blue Texas
    • Humana
    • Independent Medical Systems
    • Integrated Health Plan
    • Medicare
    • The Miers Group 
  • Multiplan PPO
  • National Preferred Provider Network
  • Nexcaliber
  • Oscar Insurance Company of Texas
  • Prime Health Services
  • Private Healthcare Systems
  • Provider Select PPO
  • Scott and White
  • Three Rivers Provider Network
  • Texas Bluebonnet
  • Tricare
  • United Healthcare
  • USA Managed Care Organization
  • Wellcare
  • XL Healthcare Improvement Plus
  • Contact Us

    Our Location:
    7000 Bryant Irvin Rd, Ste 100
    Fort Worth, TX 76132

    Tel: 817.882.6338
    FAX: 817.759.9808

      [recaptcha theme:dark]