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CLIENT
Name:
*
Address
Street Address
Street Address Line 2
City
State
Postcode
Date of Birth
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1902
1901
year
Phone
Email
CLIENT INJURY
Injury Date
*
Injury
*
At work
*
Yes
No
Occupation
*
Pre-injury average wage
*
Pre-injury hours
*
Claim Number
*
EMPLOYER
RTW Coordinator
*
Company
*
Employer Address
Street Address
Street Address Line 2
City
State
Postcode
Telephone
Employer Email
DOCTOR
Doctor
*
Doctor Address
Street Address
Street Address Line 2
City
State
Postcode
Medical Reports / Certificates
Doctor Telephone
Doctor Email
AGENT / PARTY RESPONSIBLE FOR THE PAYMENT OF ACCOUNTS
Agent Contact Name
*
Agent Address
Street Address
Street Address Line 2
City
State
Postcode
Liability accepted
*
Yes
No
Agent Telephone
Agent Email
APPROVAL IS HEREBY GIVEN FOR REHABCO TO UNDERTAKE THE FOLLOWING SERVICES:
Services
Workplace Rehabilitation Services up to the development of a Return to Work Plan
Home Assessment
Workplace Assessment
Driving Assessment
Vocational Assessment (for Suitable Employment)
Exercise Physiology Services
Earning Capacity Assessment
Work Conditioning
Functional Capacity Assessment
Psychological Counselling Services
Workplace Based Functional Capacity Assessment
Bullying and Harassment Intervention
Ergonomic/Workstation Assessment
Mediation and Conflict Resolution
Labour Market Analysis
Medico Legal Assessment
Job Seeking Skills Programme
Pre-employment Functional Screening
Targeted Assistance for Work Capacity Decisions
Employer Education Services
Initial Assessment or NTD Case Conference
OHS Services
Activities of Daily Living Assessment
Other
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