Preferred Program
*
Active Recovery Clinics (ARC) - Specialised MSK Injury Treatment Program with Mental Health Support
Navigator Support Program (NSP) - Mental Health Support for Physical Injuries
Primary Psychological Program (PPP) - Psychological Treatment Program
Early Intervention (EI) - Early Intervention Program, Pre-Claim Only
Chronic Injury Program (CIP) - Specialised Program for Tail Claims
Unsure (Navigator Group will contact you)
Do you have a preferred Navigator clinician?
*
Yes
No
Name of preferred clinician:
Claimant Information
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Phone Number
*
Claim Number
*
Do you have a Certificate of Capacity to attach?
*
Yes
No
Do you have a Certificate of Capacity to attach?
*
Please Select
Yes
No
Supporting documents (Certificate of Capacity, scan results, etc.)
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Mailing Address
*
Address
Apt/Unit/Lot, etc.
City
State
Postcode
Employer
Broker (if applicable)
Injury Details
Date of Injury
*
-
Day
-
Month
Year
Body Part
*
Please Select
Neck
Shoulder
Back
Hip
Knee
Ankle
Psychological
Other
Left or Right (if applicable)
Left
Right
Both
Insurance Information
Insurance Company
Please Select
QBE
EML
Allianz
Gallagher Bassett
Suncorp/GIO
DXC
Other
Insurance Company (if other)
Insurance Company State
Please Select
NSW
VIC
ACT
WA
QLD
NT
SA
Insurance Company Agency
Ie. QBE IfNSW, EML RTWSS, QBE AP, SUNCORP CTP, ALLIANZ IfNSW
Insurer Team Name
Case Manager Details:
Name
*
First Name
Last Name
Email
*
case-manager@example.com
Phone Number
-
Area Code
Phone Number
Treating Doctor Details:
Name
First Name
Last Name
Phone Number
Fax Number
Email
example@example.com
Treating Physiotherapist Details:
If applicable
Name
First Name
Last Name
Provider Company
Phone Number
Please enter a valid phone number.
Additional Information
By submitting this referral, I agree to the initial program costs for Navigator Group to a maximum cost of $1600.Upon submitting this referral you will receive a confirmation email with services included and applicable codes
*
I agree
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*
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