• Consent Form

    COH Services Pty Ltd (COH Rehab) collects the details and choices you provide to record your provider nomination and consent instructions and support the services we provide for this claim. If essential details are missing, we may be unable to record or act on your instructions. Jotform hosts this form and processes your answers. Jotform currently stores these form submissions in the United States. Read our Privacy Policy for information about how we handle your information, technology providers, access, correction and complaints. Questions: Charlie@cohrehab.com.au or 0477 224 404.
  • Privacy policy: Privacy policy

  • Consent to Share Information

  • Format: (000) 000-0000.
  • Date of Birth
     / /
    2 digit day, 2 digit month, 4 digit year

  • I nominate COH Services as my rehabilitation provider under the CTP Scheme.

    To support effective collaboration with your support team and relevant stakeholders, COH Services will be required to collect, use, and disclose information related to my claim.

    By signing below, I authorise COH Services to obtain, share, and disclose relevant information, whether verbal or written, in relation to my ongoing CTP claim and occupational rehabilitation with relevant parties:

    ☒ My Treating Doctor and Specialists

     ☒ SIRA

    ☒ Other Relevant Party

    ☒ Trade Union

    ☒ Client’s Solicitors

    ☒ Insurance Company

    ☒ Medical / Health Professional

    ☒ Employer

  • Information-sharing choices — effective 5 October 2026

  • Provider nomination: I nominate COH Services Pty Ltd (COH Rehab) as my preferred rehabilitation provider for my NSW CTP claim. This nomination is separate from the information-sharing choices below. Choose Yes or No for each recipient below. Choose No if a category does not apply to you. A Yes authorises COH Services Pty Ltd (COH Rehab) to obtain information from and disclose information to that recipient, limited to the relevant information and purpose described below. A No means this form does not authorise either collection from or disclosure to that recipient. An unanswered recipient choice does not authorise collection from or disclosure to that recipient. It does not automatically exclude you from services; COH Rehab can discuss any practical implications with you. You can change or withdraw your choices by contacting COH Rehab. Changes apply to future collection and disclosure that relies on your consent. They do not undo earlier lawful handling or remove legal record-keeping obligations. Signing confirms your choices and does not override a No. A signature collected under an earlier version does not confirm the choices in this version. These choices do not prevent a disclosure required by law.
  • My treating doctor and specialists involved in this CTP claim Relevant injury, treatment, functional capacity and rehabilitation information, to coordinate my care and recovery for this claim.*
  • NSW State Insurance Regulatory Authority (SIRA) Relevant claim and rehabilitation/service information, for queries or oversight concerning this CTP claim.*
  • The trade union representing me in relation to this claim Work capacity, restrictions, suitable duties, adjustments and return-to-work arrangements, for workplace representation and support relating to this claim. This choice does not authorise disclosure of your diagnosis, medical history or detailed treatment records. Separate specific authorisation would be needed unless disclosure is required by law.*
  • My solicitor representing me in this CTP claim Relevant claim, injury and rehabilitation information, to assist my solicitor's representation of me in this claim.*
  • The insurer managing this CTP claim Relevant claim, functional capacity, treatment and rehabilitation progress information, for management of this claim and coordination of rehabilitation.*
  • Other treating medical or health professionals involved in my care for this injury Relevant injury, treatment, functional capacity and rehabilitation information, to coordinate my care and recovery for this injury.*
  • My employer involved in my return-to-work arrangements for this claim Work capacity, restrictions, suitable duties, adjustments and return-to-work plans only, to coordinate my return to work. This choice does not authorise disclosure of your diagnosis, medical history or detailed treatment records. Separate specific authorisation would be needed unless disclosure is required by law.*
  • Date
     / /
    2 digit day, 2 digit month, 4 digit year
  • Should be Empty: