Workers' Compensation Appointment Request
Please complete all of the information requested in the form below. Please note that the asterisk (*) items are required to complete your appointment request.Once your request has been submitted, we will contact you. Appointments will be seen within 24 hours and in some cases the same day.
Patient Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Preferred Language
*
Please Select
English
Spanish
Appointment Details
Preferred Office Location
*
Please Select
First Available
Gilbert
North Peoria
Peoria
Queen Creek
Scottsdale (Osborn)
Scottsdale (Shea)
Scottsdale (Thompson Peak)
Show Low
Tempe
Preferred Provider
*
Please Select
Michael Chang, MD (Spine Surgeon)
Dennis Crandall, MD (Spine Surgeon)
Terrence Crowder, MD (Spine Surgeon)
Jason Datta, MD (Spine Surgeon)
Farhad Mosallaie, DO, PhD (Pain Management)
Alec Sundet, MD (Spine Surgeon)
Lyle Young, MD (Spine Surgeon)
Employer Information
Employer
*
Contact Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Insurance Information
Carrier
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Fax
*
Please enter a valid phone number.
Claim Number
*
Date of Injury
*
-
Month
-
Day
Year
Date
Adjuster
*
First Name
Last Name
Adjuster Phone
*
Please enter a valid phone number.
Adjuster Fax
*
Please enter a valid phone number.
Body Part Injured
*
Authorized by
*
Do we contact this person for Authorization?
*
Yes
No
Service Authorized
Select which services that you authorize (check all that apply):
Consult and X-Rays Only
Consult and Treat
Second Opinion
Records Request:
Any contacts that may require records from your visits
Adjuster
Adjuster Name
First Name
Last Name
Adjuster Phone Number
Please enter a valid phone number.
Adjuster Email
example@example.com
Adjuster Fax Number
Please enter a valid phone number.
Fax Records?
Yes
No
Referral Source
Referral Source: Name/Clinic Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Fax Number
Please enter a valid phone number.
Fax Records?
Yes
No
Nurse Case Manager
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Fax Number
Please enter a valid phone number.
Fax Records?
Yes
No
Medical Information
Please select what you are sending
All medical reports/records faxed
X-Rays (please hand carry with you if possible)
Please verify that you are human
*
Submit
Should be Empty: