Return to work - Referral request form
To learn more or if you have any questions, please email referrals@habit.health or call Rachel Williams on 021 411 029.
Client details
Client’s full name
First Name
Last Name
Date of birth
-
Day
-
Month
Year
Date
Claim number
NHI number
Client's mobile number
-
Area Code
Phone Number
Email
example@example.com
Preferred key worker (if any)
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Reason for referral
Injury type
Date of injury
-
Day
-
Month
Year
Date
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Checklist
(can be completed by Employer, GP/Specialist or Habit Health Staff/Subbie)
Compulsory
*
Employee has consented to return to work input
Current ACC Claim
Is struggling to complete usual duties
Has a current Medical Certificate that is either FUF (fully unfit) or FFSW (Fit for Selected Work)
Referral likely indicated (with approval from ACC)
There may be suitable, alternative or light duties that the staff member could do at work
The client/staff member is ready to return to work in some capacity
If the client does not meet any of the criteria specified above but you consider that, the client would benefit from support: we can still discuss this with you and make recommendations
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Employer (company name)
*
example@example.com
Employer (company) address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referrer's full name
*
First Name
Last Name
Referrer's Email
*
example@example.com
Electronic signature
Date
-
Month
-
Day
Year
Upload necessary documents
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