Treatment Authorization Form - Next Level Urgent Care

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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.

Method of being seen: *

Please call patient to schedule
Patient will be a walk-in

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

What are you coming in for? *

Work Injury
Physical
Drug or alcohol testing

Please make a selection:

Work injury only visit
Work injury with drug and alcohol testing

Which type of physical?

DOT Physical
General Non-DOT Physical

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

Urine Drug Screening Needed? *

DOT
Non-DOT Instant (e/mCup 10-Panel)
Non-DOT Instant (e/mCup 5-Panel)
Non-DOT Send to Lab (10-Panel)
Non-DOT Send to Lab (5-Panel)
Service Not Needed

DOT Agency

FMCSA
FAA
FTA
PHMSA
USCG
FRA

Reason For Drug Screening

Preemployment
Random
Reasonable Suspicion
Post-Accident
Return to Duty
Follow Up

Breath Alcohol Testing (BAT) Needed? *

DOT
Non-DOT
Service Not Needed

TB Testing Needed? *

TB Testing
TB Chest X-Ray
Service Not Needed

Specify which specialty physical is needed:

Date of Injury - Leave blank if not applicable

Job Title *

Description of Incident if applicable

Any Special Instructions?

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