Call Ahead Care Line: (281) 783-8162

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 worx@nlucc.com or call 832-706-2295 so that we can assist you or your employee prior to the requested visit.

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 *

Clear Signature

Please attach employee job description if available.

Click or drag a file to this area to upload.

Which region will the patient be testing in?

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)

Pre-Employment Services: *

Work Injury Testing: *

Breath Alcohol Testing (BAT) Needed? *

DOT
Non-DOT
Service Not Needed

Physical Needed? *

DOT Physical
General Non-DOT Physical
Specialty Physical
Service Not Needed

Any Special Instructions?

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Treatment Authorization Form

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