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

Have you used Next Level in the past for Pre-Employment/Work Injury Services?

Reason for Visit:

Information

Patient Name:

First Name

Last Name

SSN/ID #:

Date of birth

Gender

Male

Female

OtherOther

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 upload the job description of the injured employee

Maximum file size: 516MB

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

What is the patient's primary language?

English

Spanish

OtherOther

Select Your Clinic Location

Please upload any relevant forms here, if applicable

Maximum file size: 516MB

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Established Employer Form

Reason for Visit:

Information

Patient Name:

First Name

Last Name

SSN/ID #:

Date of birth

Patient Address

Patient Phone

Job Title:

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

Company Name

Date of Injury

Description of Incident and Special Instructions:

Visit Method:

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

Patient will walk in

Select Your Clinic Location

Job description attachment

Maximum file size: 516MB

Captcha

If you are human, leave this field blank.

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Early Clinic Closure

Our clinics will be closing early at 7 PM today, October 31st.

We will resume normal business hours (9 AM – 9 PM) tomorrow, November 1st.

Thank you for your understanding. Wishing you a happy and safe Halloween!