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COVID-19/Antibody FAQ
What We Treat
Antibody Testing
Illnesses
Injury
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Immunizations & Vaccines
Back Pain
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Arizona
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Plan Your Visit
Primary Care
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Coronavirus (COVID-19)
Curbside
Insurance We Accept
Pre-Visit Forms
Medical Discount Program
Pay Your Bill
FAQ
COVID-19/Antibody FAQ
What We Treat
Antibody Testing
Illnesses
Injury
Physicals
Pediatrics
X-rays
Lab Services & STD Testing
Immunizations & Vaccines
Back Pain
Health Resources
Occupational Health
Workers’ Compensation
Employer Services
DOT Physicals
Employer Benefits
Step
1
of
6
16%
Contact Us
Name
(Required)
First
Last
Company Name
(Required)
Email
(Required)
Phone
(Required)
What State Are Your Inquiring About?
(Required)
Arizona
Colorado
Kansas
Michigan
Missouri
Nebraska
New Mexico
North Carolina
Oklahoma
Texas
Virginia
Wyoming
Please Select All That Apply
Austin
DFW East & Waco
DFW West & Abilene
Houston
San Antonio
South Texas
Would like to complete company protocols online or have someone contact you?
(Required)
Yes, complete online
No, have someone contact me
Business Name
Legal Business Name (If Differs)
Physical Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Number of employees:
1-50
50-100
100+
Number of locations:
Do these protocols apply to all locations?
Yes
No
Primary Contact Name
First
Last
Primary Contact Phone
Primary Contact Alternate Phone
Primary Contact Email
Primary Contact Job Title
Secure Fax
Is your billing address the same as your physical address?
Yes
No
Billing Contact Name
First
Last
Billing Contact Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Billing Contact Email
Billing Contact Phone
Would you like to list a secondary contact?
No
Yes
Secondary Contact Name
First
Last
Secondary Contact Phone
Secondary Contact Alternate Phone
Secondary Contact Email
Secondary Contact Job Title
Secondary Contact Fax
Will your company use NextCare for the treatment of work related injuries?
No
Yes
Insurance Carrier Name
Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Policy Number
Phone
How would you like the work statuses reported?
Fax
Email
Send with Employee
Company Contact
Same as primary
Same as secondary
Other
Name
First
Last
Phone
Email
Any additional comments or special instructions?
Will your company use NextCare for drug testing?
No
Yes
Drug screen services are billed to:
Company
Third Party Administrator (TPA)
Candidate/Employee
Name of TPA
Who is the Designated Employer Representative?
Primary Contact
Secondary Contact
Other
Type
DOT / Federal
Federal
Non-DOT
Federal
HHS
NRC
DOT Agency
FMCSA
FAA
FRA
FTA
PHMSA
USCG
Lab and Medical Review Officer Services (MRO):
Full Service (use NextCare’s Lab and MRO)
Collection Only (use your company’s existing Lab Account and MRO)
Drug Screen Collection Method:
Urine
Hair
Saliva
Other
Testing Type:
*Rapid testing is not available in our Kansas market. Non-negative rapid test results are sent-out to lab for confirmatory testing and MRO review prior to result reporting.
Send-out to laboratory for testing (results available in 3-5 days)
Rapid / Quick Test (negative test results available same day)*
Rapid / Quick Test Panels:
5 Panel Rapid
11 Panel Rapid
Other
Send-Out Panels:
5 Panel
9 Panel
10 Panel
12 Panel
Other
Would your company be interested in learning about NextCare’s random management program?
Yes
No
Name of Lab
Lab Account Number
Reason for Test:
Pre-Employment
Random
Return to Work
Reasonable Suspicion
Post Accident
Follow-Up
Secured Method of Reporting
Fax
Email
Additional Notes/Comments:
Would you like to add another drug screen to your account?
Yes - An Occ Health Team Member Will Follow Up For More Details
No
Will your company use NextCare for physical examinations?
No
Yes
Basic Physical (includes vitals, review of medical history and physical exam)
DOT Physical
Return To Work
Other
Physical Services are billed to:
Company
Third Party Administrator (TPA)
Candidate/Employee
Name of TPA
Authorized recipients:
Primary Contact
Secondary Contact
Other
Name
First
Last
Phone
Secure Fax
Email
NextCare offers many other Occupational Health services, please use this box to list any other testing, vaccines, lab testing or other services you may need.
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