Workplace OH&S Solutions - Online Referrals

Online Referrals

Referral for Injury Management Services

Injured Worker Surname

Injured Worker First Name

Injured Worker Address

Injured Worker Phone

Injured Worker Date of Birth

Interpreter

Yes

Language

Injury Details

Date of Injury

Type of Injury

Occupation

Claim Number

Selected Duties

Yes

Unknown

Status

Date Ceased/Terminated

Employer

Employer Address

Employer Phone

Employer Fax

Employer Email

Rehab Coordinator

Supervisor

Insurance Company

Insurer Address

Insurer Phone

Insurer Fax

Insurer Email

Insurer Contact

WorkCover Provider No. 529
Comcare Provider No. 19065779

Referral for Injury Management Services

WorkCover Provider No. 529
Comcare Provider No. 19065779

Treating Doctor

Dr Name

Dr Address

Dr Telephone Number

Dr Email

Referral to

Comments

Approval for Injury Management Services
Approval is hereby given to undertake an initial rehab assessment up to the development of a plan or as otherwise specified.

Referrer

Date

Insurer/Employer/Other

Liability Status

Accepted

Denied

Reason for Referral

Online Referrals

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