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Menu
Patient Care
New Patient Information
Patient Portal
Insurance and Self-Pay Rates
Pay Your Bill Online
Sports Physicals
Request Medical Records
Pre-Paid Visit Bundles
COVID-19
COVID-19 Testing Options
COVID-19 Vaccine
Locations
Baytown
Champions
Cinco Ranch
Conroe
Copperfield
Cypress
Falcon Landing
Katy
Kingsland
League City
Long Meadow
Meyerland
Pearland
Sienna Plantation
Sugar Land
Tanglewood
The Woodlands
About Us
Contact Us
FAQ
Careers
Sponsorship Requests
Press Releases
Become a Preferred Physician
Blog
Health XPlained Podcast
Employer Solutions
Next Level PRIME
Work Injury Management
Onsite Clinic
Nearsite Subscription
COVID-19 Safety Program
Workplace Health Blog
Treatment Authorization Form
Client Login
Research
Open 7 Days a Week Until 9PM
Treatment Authorization Form
Please complete the form below before you arrive to the clinic for your appointment.
If you have any questions or concerns, please email
physicals@nlucc.com
or call
281-895-3566
so that we can assist you or your employee prior to the requested visit.
Alternatively, click here to download a printable version of the form.
Please enable JavaScript in your browser to complete this form.
Patient Name
*
First
Last
SSN/ID #
*
Date of Birth
*
MM
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YYYY
2021
2020
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2016
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2014
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2012
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2003
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1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Patient Phone
*
Company Name
*
Company Phone
*
Company Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Company Contact
*
First
Last
Company Contact Email
*
Company Contact Direct Number
*
Company Contact Signature
*
Clear Signature
Please attach employee job description if available.
Click or drag a file to this area to upload.
Which clinic will the patient be testing at?
*
Baytown
Champions
Cinco Ranch
Conroe
Copperfield
Cypress
Falcon Landing
Katy
Kingsland
League City
Long Meadow
Meyerland
Pearland
Sienna Plantation
Sugar Land
Tanglewood
The Woodlands
Who should we bill for this service?
*
Employer (see address above)
Employee to pay at time of service
Workers Compensation (report injury to Insurance Company)
Insurance Company Name
*
Insurance Company Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Insurance Company Phone #
*
CLM #
*
Pre-Employment Services:
*
Yes
No
Work Injury Testing:
*
Yes
No
Urine Drug Screening Needed?
*
DOT
Non-DOT Instant Read
Non-DOT Send to Lab
Service Not Needed
BAT Needed?
*
DOT
Non-DOT
Service Not Needed
Date of Injury
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Job Title
*
Description of Incident
*
Any Special Instructions?
Submit
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