Medicolegal / NDIA Booking Form
Our MRO Clinician will contact the client 24 hours prior to the assessment to conduct a home visit safety check and to ensure they are healthy and well. Please ensure that you have provided the claimant’s phone number below.
Type of referral
*
Medicolegal Report
NDIA / NDIS Tribunal Report
REFERRER DETAILS
Company and Referrer contact:
*
Company Name
Referrer's Full Name
Referrer Contact details:
*
Phone number
Email address
Solicitor's Details:
Full Name
Phone number and Email address
Case / Reference Number:
*
CLAIMANT DETAILS
PARTICIPANT DETAILS
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Postal Code
Date of Birth
*
-
Month
-
Day
Year
Date
Date of subject incident
-
Month
-
Day
Year
Date
Contact Details
*
Phone number
email address
Injuries / Diagnosis
*
Diagnosis / condition
*
Is the participant seeking eligibility to the scheme?
*
Yes
No
Already in the scheme
Is the matter due to go to the Administrative Review Tribunal?
*
Yes
No
(Yes) Please select Date
-
Month
-
Day
Year
Date
Interpreter Required (It is the referrer's responsibility to organise an accredited interpreter to be present for the assessment if one is required).
*
Yes
No
Interpreter Details:
Language and contact details
Communication Barriers
*
Yes
No
Communication Barrier Details:
ASSESSMENT / REPORT DETAILS
Type of matter
*
Public Liability
Motor Vehicle Accident
Personal Injury
Workplace Accident
Medical Negligence
Other
(Other) Please provide details
Type of Medicolegal Report required:
*
Standard Occupational Therapy Medicolegal Report
Complex Occupational Therapy Medicolegal Report
Independent OT Opinion
Details regarding the dispute:
*
Type of NDIA Report required:
*
ART Tribunal Report on Functional Capacity
ART Tribunal Report on Specialist Disability Accommodation
Independent OT Opinion
Date Report is required by (our report turnaround is 4 weeks from date of assessment)
-
Month
-
Day
Year
Date
SAFETY
Are there any known risks (including violence, aggression, drug / alcohol use or behaviour) which would place our MRO staff at risk conducting a home assessment?
*
Yes
No
(Yes) Please provide details
Has the client had a history of behavioural problems or psychological disorders which may place our staff at risk?
*
Yes
No
(Yes) Please provide details
Submit
Should be Empty: