Treatment Authorization Form - Next Level Urgent Care

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Patient Care
COVID-19
- COVID-19 Testing Options
- At-Home Proctored Testing
Locations
About Us
Employer Solutions
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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.

Patient Name *

First

Last

SSN/ID # *

Date of Birth *//

Patient Phone *

Company Name *

Company Phone *

Company Address *

Address Line 1

Address Line 2

City

State

Zip Code

Company Contact *

First

Last

Company Contact Email *

Company Contact Direct Number *

Company Contact 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? *

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

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 *//

Job Title *

Description of Incident *

Any Special Instructions?

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