• You have been scheduled to see Dr. Michael Wallerich for a neuro-optometric evaluation. He will evaluate your visual skills and evaluate your eye health as related to your brain injury. Completion of this form does not guarantee eligibility and coverage. Ultimately, that is determined by your Worker’s Compensation Insurer. Wallerich Eye Care will provide all necessary documentation to you and requested parties (with written consent only by medical release form) to support your eye & vision care needs. This form must be completed priorto your evaluation. It is advised that you have a referral from your treating health care provider & a claim authorization number (provided by your Worker’s Compensation Insurer) prior to your assessment. All services provided will be billed the usual & customary charges, which is ultimately your responsibility. Wallerich Eye Care will assist you by providing all necessary documents to be able to submit for this visit.
  • Patient Information (Patient or Employer to Complete):

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  • Worker’s Compensation (Employer to Complete)

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  • Northland Billing BELOW

  • Dates Unable to Work:
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