COH Rehab Referral Form

COH Rehab Referral Form

Submit a referral with client and claim details, requested services, and supporting documents for COH Rehab review.
COH Rehab’s core focus is CTP rehabilitation. COH Rehab does not provide general workers compensation workplace rehabilitation; WorkCover referrals are limited to ADL assessments and applicable OTT005 services.
Referrer Full Name

First NameLast Name
Referrer Organisation
Referrer Role/Position
Referrer Phone Number

Area CodePhone Number
Referrer Email Address
example@example.com
Referral Source
Client Full Name

First NameLast Name
Client Date of Birth

DayMonthYear
Date
Client Phone Number

Area CodePhone Number
Client Email Address
example@example.com
Client Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Claim Type

Private/Other
Insurer Name
Claim Number
Insurer Contact Name
Insurer Contact Email
example@example.com
Requested Service
Injury Date

DayMonthYear
Date
Diagnosis/Injury Summary
Current Treating Providers
Referral Reason and Goals
Urgent Risks or Accessibility Needs
Preferred Contact Method

Other
Upload Referral Documents

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I confirm I have the authority to provide this information.
I confirm that client consent has been obtained or will be completed separately.
I acknowledge and accept the privacy policy.
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