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 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

Details

Insurer Details

Given names

Surname

Date of birth

Employer name

Phone

Address

Insurer/Claims Service Provider

EML

icare

Allianz

QBE

SML

Other

TMF

DXC

Trinity

HII

Case Manager Given Names

Case Manager Surname

Case Manager's Email

Case Manager's Phone

Notes

Service Request Details

Referral Date

Service Costs Approved

Referral Code

OAS002

OR01

OR02

OR03

Consulting

Goal/Expected Outcome

Brief history

Barriers/Key Information

Special Instructions

Pre-injury Hours

Injured Worker Details

Claim Number

Date of Birth

Date of Injury

Diagnosis

Pre-Injury Occupation

PIAWE

Pre-injury Duties

Aware of Referral

Yes

N/A

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

Other File

Drop File Here

Upload a File

Upload a file

Declaration

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.