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.

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

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

Reason for Visit:*

Additional Reason:

Patient Name*

First Last

SSN/ID #:*

Date of birth*

Gender

Male

Female

Other

Patient Address*

Street Address Address Line 2 City State ZIP Code

Patient Phone*

Job Title:*

Company Name:*

Company Phone:*

Company Address:*

Street Address Address Line 2 City State ZIP Code

Company Contact*

First Last

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

Employee Contact Email (a copy of this submission will be sent to this email)*

Company Contact Direct Number:*

Company Contact Signature*

Billing Method:*

Employer (see address above)

Employee to pay at time of service

Workers Compensation (report injury to insurance carrier)

Billing Method: UDS and BAT services can only be provided with an ePassport or payment at time of service*

Employee to pay at time of service

Workers Compensation (report injury to insurance carrier)

Insurance Carrier Name:*

Insurance Carrier Address:*

Street Address Address Line 2 City State ZIP Code

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

Immunizations Required:*

Hepatitis

MMR

Flu

Tdap

Varicella

PPD

No immunizations Required

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

Accepted file types: png, gif, doc, docm, docx, pdf, jpg, jpeg, jpe, Max. file size: 500 MB.

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

Other

Select Your Clinic Location*

Please upload any relevant forms here, if applicable

Accepted file types: png, gif, doc, docm, docx, pdf, jpg, jpeg, jpe, Max. file size: 500 MB.

"*" indicates required fields

Instagram

This field is for validation purposes and should be left unchanged.

Reason for Visit:*

Patient Name*

First Last

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

Accepted file types: png, gif, doc, docm, docx, pdf, jpg, jpeg, jpe, Max. file size: 500 MB.

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