Forms & Policies

Your referring physician must fax us a referral, results of pertinent studies (i.e. MRI, EMG) and previous care to our office. If we do not receive this information in a timely manner, it will delay your care or we may need to reschedule your appointment.New York Spine & Sport Rehabilitation Medicine Office Fax: 718.794.9899

Please complete out the appropriate

New Patient Information from our website.

New Patients Information Form | Download

New Patient Information for Work Related Injury Form | Download

New Patient Information for Motor Vehicle Accident Form | Download

You may fax or email this information with a copy of your insurance card prior to your appointment or bring the completed forms and your insurance card the day of your appointment.If your pain is related to a work related injury or a motor vehicle accident please provide us with the assigned case number and required info as per the particular New Patient information sheet. Please do not use your medical insurance if your pain/injury is related to a reported work related injury or motor vehicle accident.

If your insurance requires prior authorization for a visit to a specialist, you must arrange for this and obtain the authorization number prior to your visit.

Insurance co-payments are due at the time of arrival. We accept cash, checks, and credit cards.

We accept most insurance programs and their subsidiaries. If we do not participate in your insurance plan, please speak to Lori our Office Manager who will check if other arrangements are possible.

Unfortunately, we cannot accept walk-in patients. If you are a new patient, please arrive 15 minutes prior to your scheduled appointment time to allow time to register.

Our practice does not prescribe narcotic medications only, we use a multi-adjuvant combination of non narcotic medications, interventional procedures, physical therapy and combination therapies such as psychological or nutrition management to control your pain condition. Please discuss your medication needs, including refill requests, with our physicians at the time of your appointment. Medications should be taken only as prescribed, if opiates are prescribed by practice you may need to sign an Opiate Contract.

Please do not request early refills of your medications. Patients are responsible for lost or stolen medications and prescriptions once they leave the office. Please do not call the office for a medication refill.

If you are scheduled for an interventional procedure, please read the procedure information carefully and bring a designated driver to transport you home. If you are unable to arrange for a driver please let our know in advance.

If you are a referring doctor please use our referral sheet. Please clearly mark and fax (we prefer fax) or send this referral sheet with the patient.

1. Referral Sheet | Download
2. Physical Therapy Prescription | Download

After regular hours, if you have a medical emergency please call 911. If you undergone a interventional procedure or need to contact Dr. Sireen Gopal or Dr. Bryan Elzholz after work hours for an emergency only, please call the Jack D Weiler Hospital Operator @718.904.2000 who can arrange to transfer your call to our staff

Billing Manager: Zaida Diaz
Office: 718.794.0600
Fax: 718. 794.-9899

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