Select a Physician:
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Please Select
1st Available Physician
Rafael Levin, MD, MSC
Nomaan Ashraf, MD, MBA
Evan Baird, MD
Jonathan Lester, MD
Office:
*
Please Select
Westwood
Bloomfield
East Brunswick
Bridgewater
CSC to Select Closest Proximity to Patient Home
**Clifton has moved to Bloomfield effective Monday, August 11, 2025**
Case Manager attends?
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Please Select
Attending
Not Attending
Appointment Type:
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I.M.E. (Prepayment Required)
One Time Evaluation / 2nd Opinion Only (No Treatment)
Need for Treatment (NFT) / Take Over Treatment
Re-Evaluation
Appointment Type:
*
Worker's Comp
Independent Medical Exam/I.M.E. (Prepayment Required)
Worker's Comp Appointment Type:
*
Initial EVAL with CSC/ Evaluation and Treatment
One Time EVAL / 2nd Opinion – No Treatment
NFT – Need for Treatment/ No Treatment
RE-EVAL – Previous CSC patients ONLY
Independent Medical Exam/I.M.E. Appointment Type:
*
Workers Compensation IME
Liability IME
Treatment Authorization:
*
Cervical
Thoracic
Lumbar
Pain Management
Studies available for review:
MRI
CT Scan
X-Ray
None
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Next: Patient Information
Patient Name
First Name
Last Name
Patient Name:
*
First Name
Last Name
Sex:
*
Male
Female
Primary Language Spoken:
*
D.O.B:
*
-
Month
-
Day
Year
Date
Last 4-Digits of S.S.N:
Home Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
example@example.com
Patient Attorney Name:
Patient Attorney Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Attorney Phone #:
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Next: Patient Address
Home Address of the Patient
*
Street Address
City
*
State/Province
*
Postal/Zip Code
*
Home Address of the Patient:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Next: Insurance Information
Insurance Carrier:
*
Please Select
AMTRUST
CCMSI
ESIS
FIRST MCO
GALLAGHER BASSETT
GREAT AMERICAN
HORIZON CASUALTY
LIBERTY MUTUAL
NJM
PMA
QUAL-LYNX
SEDGWICK
SELECTIVE
THE HARTFORD
TRAVELERS
ZURICH
Other (Enter Below)
Other Insurance Name:
*
Other Insurance Address:
*
Address of the Claim Office:
*
Please Select
AMTRUST P.O. BOX 89404 CLEVELAND, OH 44101
Address of the Claim Office:
*
Please Select
CCMSI PO BOX 1127 NEPTUNE, NJ 07754
Address of the Claim Office:
*
Please Select
ESIS PO BOX 6566 SCRANTON, PA 18505
Address of the Claim Office:
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Please Select
FIRST MCO PO BOX 211461 EAGAN, MN 55121
Address of the Claim Office:
*
Please Select
GALLAGHER BASSETT PO BOX 2831 CLINTON, IA 52733
Address of the Claim Office:
*
Please Select
GREAT AMERICAN PO BOX 4080 CLINTON, IA 52733
Address of the Claim Office:
*
Please Select
HORIZON CASUALTY PB BOX 10175 NEWARK, NJ 07101
Address of the Claim Office:
*
Please Select
LIBERTY MUTUAL P.O. BOX 7203 LONDON, KY 40742
Address of the Claim Office:
*
Please Select
NJM 301 SULLIVAN WAY W. TRENTON, NJ 08628
Address of the Claim Office:
*
Please Select
PMA P.O. BOX 5231 JANESVILLE, WI 53547
Address of the Claim Office:
*
Please Select
QUAL-LYNX PO BOX 211156 EAGAN, MN 55121
Address of the Claim Office:
*
Please Select
SEDGWICK PO BOX 14545 LEXINGTON, KY 40512
SEDGWICK PO BOX 14151 LEXINGTON, KY 40512
Address of the Claim Office:
*
Please Select
SELECTIVE P.O. BOX 7252 LONDON, KY 40742
Address of the Claim Office:
*
Please Select
THE HARTFORD P.O. BOX 14187 LEXINGTON, KY 40512
Address of the Claim Office:
*
Please Select
TRAVELERS P.O. BOX 4614 BUFFALO, NY 14240
Address of the Claim Office:
*
Please Select
ZURICH PO BOX 968044 SCHAUMBURG, IL 60196
Claim:
*
Date of Accident:
*
-
Month
-
Day
Year
Date
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Employer:
*
Employer Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Work Status:
*
Occupation:
*
Employer Email Address:
example@example.com
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Next: Adjuster Information
Adjuster Name:
*
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Extension
*
If no extension is needed please enter 0000.
Fax Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
*
example@example.com
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Next: Nurse Case Manager
Nurse Case Manager Name:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Extension:
Fax Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
example@example.com
Scheduler: (Leave Blank if Not Applicable)
Scheduler Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Scheduler Extension:
Email Address:
example@example.com
Relationship to insurance company:
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Next
Patient allowed to adjust date/time?
*
Yes, the patient is allowed to make adjustments to the appointment. (If the patient makes any adjustments, we will notify by email.)
No, the patient is not allowed to make adjustments to the appointment.
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Next
I authorize Comprehensive Spine Care, P.A. to treat the above patient.
*
Please Type Your Name
Signature
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Extension
*
If no extension is needed please enter 0000.
Email
*
example@example.com
Additional Comments:
Note: All online appointment submissions will be responded to within 24 hours with the appointment date and time
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