Urgent Care Support Team
Resume:
Experiencing issues? Please contact
our support team at 877-***-****.
INSTRUCTIONS:
You must enter/scan the authorization number above and complete the services below in FormFox to be automatically paid for these Marketplace services. SERVICES TO PROVIDE:
Non-DOT Urine Pre-Employment Urine VFF.NON1.REF1
Clinical Specimen Collection Pre-Employment VFF.CHEM.REF1 REASON FOR TEST: ACCOUNT #:
HHS
12495 Silver Creek Rd
Dripping Springs, TX 78620
michelle
Do not write in services below.
EMPLOYER: DER:
GUARANTOR/RESPONSIBLE PARTY: CRL/FormFox Marketplace Do not invoice the client/TPA for these Marketplace services. DONOR INFORMATION
YOUR SITE IS:
Westfield Urgent Care
2020 FM 1960 Rd
Houston, TX 77073-2404
INSTRUCTIONS:
CALL the site to confirm hours and if an appointment is needed at 281-***-****.
BRING THIS FORM and a VALID PHOTO ID to the site.
Your visit must be completed before 1:53 PM on March 04, 2025 CST. MIKE VILLARREAL
EmpID: LULR
CLINIC INFORMATION
Contact this candidate