Make a referral

REFERRER DETAILS

*Company Representative Name

Your Role

Case Manager Team Leader IMA Employer Nominated Treating Doctor Treating Practitioner

*Name of Company

*Address

*Phone

*Email

*Type of service required

Activity of Daily Living (ADL) Assessment Case Conference DMS - Disability Management Services (DEEWR) Ergonomic Assessment Job Seeking Labour Market Analysis Medico Legal Assessment OHS Consultancy and Training Occupational Rehabilitation Pre Employment Screening Section 40 Assessment Vocational Assessment Workplace Assessment Functional Capacity Evaluation Comparable Earnings Task Analysis / Suitable Duties Register Psychological RTW services Regional RTW services (Physical) Regional RTW services (Psychological) RTW Same Employer Services RTW New Employer Services

Notes

WORKER DETAILS

*Name

*Address

*Phone

*Date of birth

*Date of injury

*Claim Number

*Region

NSW - Sydney Metro NSW – Blue Mountains NSW - Central Coast NSW – Central West NSW - Illawarra NSW – North Coast NSW – South Coast NSW – Southwest/Riverina

Type of injury

Physical injury Psychological injury

Details of injury

(eg, shoulder, lower back, knee, psych etc)

Current work Capacity status

Has a current work capacity No current work capacity

RTW Goal

RTW Same Employer RTW New Employer

PIAWE

Pre-Injury Hours

Current Certificate of Capacity
Details

(eg hours, lifting capacity etc)

Pre-Injury Occupation

Interpreter required

No Yes

Language

AGENT / INSURER DETAILS

Click here if same as referrer details

EMPLOYER DETAILS

Click here if same as referrer details

NTD details

NTD Name

Address

Phone

Fax

Supporting Documents

Please attach any relevant medical documentation, the current certificate of capacity, recent IME/IMC reports, treating providers/specialists reports etc

File 1:
File 2:

NOTE:
You can attach up to 2 files.
Only upload files under 2mb.
If you have more than 2 files, please zip them all into a single archive.