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):Full Name First Middle Last Date of Birth MM slash DD slash YYYY Gender Male Female SSN Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork/Cell PhoneWorker’s Compensation (Employer to Complete)Insurance Plan Name PhoneContact Person Address Street Address City State / Province / Region ZIP / Postal Code Policy/Claim # Authorization # Employer Address Street Address City State / Province / Region ZIP / Postal Code Form Completed by (print first/last names) First Last Employer SignatureDate MM slash DD slash YYYY Northland Billing BELOWDate of Injury Patient unable to work Dates Unable to Work: MM slash DD slash YYYY to MM slash DD slash YYYY Able to return to Work Date Patient able to work a “Limited” schedule Number of hours per week Initial Visit Date (not injury date) MM slash DD slash YYYY Diagnosis: Medical Records/Billing Sent to Northland Billing Services
