WorkCover/CTP Referral Form

WorkCover/CTP Referral Form

Please fill out the referral form below for WorkCover and CTP patients.

Personal Information (Injured Person)
Name*

Prefix (Mr., Mrs., etc)First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender
Phone Number*

Area CodePhone Number
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Workers Compensation / CTP Details
Claim Number*
Date of injury/accident*

MonthDayYear
Date
Compensable injury/illness*
Pre-injury occupation*
Type*

Work CoverCTP
Allied Health Discipline*

PhysiotherapyExercise Physiology
Nominated Treating Doctor
Name*

First NameLast Name
Practice*

Employer
Company Name*
Employer Contact*

First NameLast Name
Employer Contact Phone

Area CodePhone Number
Employer Contact Email*
example@example.com

Insurance Company
Company Name*
Case Manager Name*

First NameLast Name
Case Manager Phone

Area CodePhone Number
Case Manager Email*
example@example.com

Referring Agent Details
Name*

First NameLast Name
Organisation
Referrer Type*

Nominated Treating DoctorPhysiotherapistSpecialistCase ManagerRehab ConsultantSelf
Upload relevant supporting documents*

Service Approval, Specialist/GP/Allied Health Practitioner reports, Scans
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