Treatment Authorization Form

Our Beaumont clinic location is closed today due to complications following Arctic Storm Enzo. All other Next Level clinic locations, including Nederland, are operating regularly and open until 9pm. We look forward to caring for you!

Treatment Authorization Form

Please complete the form before you arrive to the clinic for your appointment. If you have any questions or concerns, please email worx@nlucc.com or call 832-706-2295 so that we can assist you or your employee prior to the requested visit.

Employer Authorization Form

Reason for Visit:

Patient Name:

First Name

Last Name

SSN/ID #:

Date of birth

Patient Address

City

State/Province

Zip/Postal

Patient Phone

Job Title:

Company Name:

Company Phone:

Company Address:

City

State/Province

Zip/Postal

Company Contact:

First Name

Last Name

Company Contact Email (a copy of this submission will be sent to this email):

Company Contact Direct Number:

Company Contact Signature

Clear

Billing Method:

Employer (see address above)

Employee to pay at time of service

Workers Compensation (report injury to insurance carrier)

Insurance Carrier Name:

Insurance Carrier Address:

City

State/Province

Zip/Postal

Insurance Carrier Phone:

Claim Number if you have it (if claim number is unavailable, please use social security number):

Pre-Employment Services Required?

Yes

Urine Drug Screening:

DOT

Non-DOT Instant Read

Non-DOT Send to Lab

Not Required

Physicals:

Non-DOT

DOT

Not Required

Breath Alcohol Testing (BAT):

DOT

Non-DOT

Not Required

Chest X-Ray Required:

Yes

Audiogram Required:

Yes

Special Instructions, if applicable:

Urine Drug Screening:

DOT

Non-DOT Instant Read

Non-DOT Send to Lab

Not Required

Breath Alcohol Testing (BAT):

DOT

Non-DOT

Not Required

Date of Injury

Description of Incident and Special Instructions:

Please note that if our clinic will be performing a Physical, Chest X-Ray, or Audiogram unrelated to a work injury, walk-in appointments are not available. A member of our team will contact the patient to schedule within one business day.

Visit Method:

Please call patient to schedule (please allow up to 1 hour for us to process the request)

Patient will walk in

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Join Us for Teddy Bear Clinic,
June 25 through June 28, 2025!

Parents and caregivers, bring your child along with their favorite teddy bear or stuffed animal to Next Level Urgent Care for a fun and friendly check-up! Join us for a great time while showing your little one that visiting the doctor can be comforting and worry-free.

*Available at Select Locations

Treatment Authorization Form

Join Us for Teddy Bear Clinic, June 25 through June 28, 2025!

Join Us for Teddy Bear Clinic,
June 25 through June 28, 2025!