Introduction

REHABILITATION PROVIDER REQUEST/REFERRAL

As allied health professionals, our HEALTH ABILITY team go to great lengths to assist & provide personalised support for workers to recover from injury, illness or conditions resulting from workplace accidents, events or situations.
We are also able to support drivers & passengers associated with motor vehicle CTP claims.

To request HEALTH ABILITY (SIRA Provider # 752) to be your rehab provider, please complete our Rehab Referral request form below.

Our team take great pride in helping injured or unwell workers recover & if you have any questions, please contact our friendly team on (02) 8317-7777.

HEALTH ABILITY is a State Insurance Regulatory Authority (SIRA) workplace rehabilitiation provider #752.

Many thanks,

HEALTH ABILITY Team

YOUR HEALTH & REHABILITATION IN SAFE HANDS

Injured Worker Details

Given names

Surname

Date of birth

Employer (Organisation)

Phone

Address

Insurer/Claims Service Provider

icare

EML

Allianz

GIO

QBE

TMF

SML

Trinity

HII

CMI

Other

Claim Number

Date of Birth

Date of Injury

Diagnosis

Pre-Injury Occupation

PIAWE

Pre-injury Duties

Aware of Referral

Yes

N/A

Notes

Insurer Details

Case Manager Given Names

Case Manager Surname

Case Manager's Email

Case Manager's Phone

Service Request Details

Referral Date

Service Costs Approved

Referral Code

OAS002

OR01

OR02

OR03

Consulting

CTP

Goal/Expected Outcome

Brief history

Barriers/Key Information

Special Instructions

Pre-injury Hours

Employer

Employer's Contact

Contact Phone

Contact email

Aware of Referral

Yes

N/A

Nominated Treating Doctor

NTD Name

Practice

Phone

Documents

Certificate of Capacity File

Drop file here, or click to select

Other File

Drop file here, or click to select

Declaration

Upload a File

Upload a file

HEALTH ABILITY - REHABILITATION PROVIDER REQUEST/REFERRAL

I certify the details contained in this form are accurate at the time of completing.

Should I wish to obtain a copy of this electronic form, I can request a digital copy at any time via calling our HEALTH ABILITY team on (02) 8317-7777.