Solutions & Outcomes

Providing better solutions and lasting outcomes.

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Referral/Approval For Occupational Rehabilitation Service

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Highlighted fields are required

Referral Details Referrer's Name:

Referrer's Telephone:

Date of Referral:

Send to this S&O office:

Referral discussed with Employer

Referral discussed with Worker

Worker's Details Claim Number:

Worker's Name:

Date of Birth:

Telephone:

Address:

Worker is currently employed

Average hours worked per week prior to injury:

Injury Details Date of injury:

Weeks between DOI and referral:

Type of injury:

Date of last recurrence (if applicable):

Liability Status Liability accepted:

Work Status Currently:

Lost time:

Date ceased work:

Date return to work:

Employer Details ANZIC Details:

Employer Name:

Rehabilitation Coordinator or Contact Name:

Telephone:

Fax:

Address:

Insurer Details

Insurance Type:

Insurer Name:

Address:

Telephone:

Fax:

Contact:

Case Manager:

Treating Doctor(s) First Doctor's Name:

Qualifications:

Address:

Telephone:

Fax:

Second Doctor's Name:

Qualifications:

Address:

Telephone:

Fax:

Interpreter

Interpreter is required

Language:

Cost of Previous Rehabilitation Cost of Occupational Rehabilitation to date:

$

Not Applicable

Instructions Rehabilitation or Service Instructions:

Attachments

Accepted file types: PDF, Word, Text, JPG, ZIP

Claim Forms:

Medical Reports:

Current Medical Certificate:

Assessment Reports:

RTW Plan:

Other:

Solutions & Outcomes

Statewide offices: Hobart, Launceston, Devonport and Burnie.

Please direct all enquiries to:

Sheree Jones
Telephone 0409 553 085
Facsimile 03 6331 4886
admin@sandoc.com.au

PO Box 5032
Launceston Tasmania 7250

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