Consent Form COH

Consent Form
Consent to Share Information

Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Claim Number
Insurance
Date of Birth

MonthDayYear
Date

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
Consent
Signature
Date

MonthDayYear
Date
Should be Empty: