Work Injury Transfer of Care Request

Transfer of Care Request

Please complete the form to request your work injury care transfer to Next Level. If you have any questions or concerns, please email worx@nlucc.com or call 832-706-2295 so that we can assist you.

If you believe your situation is unique or you have questions about these criteria, please contact your adjuster to reach out to our Worx Team (which can be forwarded to COE or other assigned individual/individuals). We are happy to review individual cases as needed.

Transfer of Care

Patient Name

First Name

Last Name

Patient Date of Birth

Patient Email

Employer Name:

Desired Clinic Location?

Check the box below to acknowledge the statement.

I understand that the goal of work injury care is functional recovery and return to work, not long-term pain management or disability.

Please upload your medical record documents here.

Maximum file size: 516MB

Has it been more than 6 months since your injury or your last treatment?

Yes

Have you been told that your work injury treatment is complete, released from care, or that you have reached maximum improvement?

Yes

Has your diagnosis been disputed or denied by the insurance carrier?

Yes

I affirm that I have answered all questions truthfully and understand that knowingly providing false or inaccurate information may result in administrative discharge.

Clear

If you are human, leave this field blank.

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Transfer of Care Request

Early Clinic Closure