Rehabilitation Provider Nomination/Consent Form

Rehabilitation Provider Nomination/Consent Form

Complete this form to nominate Born Fit as your preferred rehabilitation provider and provide consent for the coordination of your treatment, recovery and return to work.
SIRA Provider Number: 1010
Email: referral@bornfit.com.au
Claim Number
Insurer
Date of Birth

MonthDayYear
Date
Address
Nominated Treating Doctor/Treater (if known)
Employer Contact (if applicable)
Insurer Case Manager Name (if known)
Insurer Case Manager Contact Number (if known)
Acknowledgment: By signing, I agree to Born Fit coordinating my treatment, recovery, rehabilitation and return to work.
Client Name*

First NameLast Name
Number*
Signature*
Date of Signature*

MonthDayYear
Date
Privacy Policy and Information Sharing Authorisation

Born Fit is committed to protecting your privacy and handling your personal and health information in accordance with applicable privacy legislation, including the Privacy Act 1988 (Cth), the Health Records and Information Privacy Act 2002 (NSW), the Privacy Amendment (Enhancing Privacy Protection) Act 2012 and the Privacy Amendment (Notifiable Data Breaches) Act 2017.

By signing this form, you authorise Born Fit to collect, use and disclose your personal and health information for the purpose of coordinating your treatment, rehabilitation and return to work.

This may include sharing relevant information with parties involved in your care and claim management, including but not limited to:

• your nominated treating doctor
• treating practitioners and allied health providers
• your insurer and case manager
• your employer or workplace representatives
• other relevant stakeholders involved in your rehabilitation

Information shared may include medical information (such as diagnosis, treatment plans and functional capacity), employment information, and claim-related information necessary to support your rehabilitation and return to work.

You may withdraw this authorisation at any time by contacting privacy@bornfit.com.au. If authorisation is withdrawn, Born Fit will cease sharing information where reasonably practicable, noting this may impact our ability to coordinate rehabilitation services.

You may request access to personal or health information held by Born Fit by contacting privacy@bornfit.com.au. Requests must be made in writing and will be managed in accordance with applicable privacy legislation.

Where reports have been prepared for an insurer or other referring party as part of a workers compensation or motor accident claim, requests for those reports should be directed to the relevant insurer.

Access to clinical records held by Born Fit may be provided in accordance with applicable privacy legislation and may be provided through a nominated treating practitioner where appropriate.

Please see below for additional information regarding Rehabilitation Providers:

https://www.sira.nsw.gov.au/__data/assets/pdf_file/0004/481396/SIRA08054_What-to-Expect-Workplace-Rehab-Provider_0419.PDF
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