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Referral Form
Comany
Insurer/Agency/Company
*
*
Branch/Division
*
*
Referrer
Case Manager First Name
*
*
Case Manager Last Name
*
*
Phone
*
*
Email
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*
*
Team Name
*
CMS Preferred Consultant
None
Amy Hampel
Jeana Peden
Jo Kwok
Kate Fleay
Katie Greene
Katie Kirkland
Linda Jeffrey
Marinda Wilson
Liz Bird
Richard Bradley
Tracey Fleming
Julie Wells
Brad Hartley
Paul Monson
Belinda Begrie
Claimant
Claimant First Name
*
*
Claimant Last Name
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*
Street Address
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*
Suburb
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*
State
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NSW
QLD
SA
TAS
VIC
WA
ACT
NT
Post Code
*
*
Email
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*
*
Phone Number
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*
Legal Involvement
Unsure
Yes
No
Please Select
Date of Birth
Day
*
*
*
Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Year
*
*
*
Employment
Pre-Injury Employer
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*
Pre-Injury Role
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*
Employment Status
Employed
Unemployed
Employer Location
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Pre-Injury Average Weekly Earnings
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*
Pre-Injury Hours
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*
Employment Start Date
Day
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*
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
*
*
Case Details
Case Number
*
*
Service Type
Worker's Compensation
Compulsory Third Party
Non Gratis
Income Protection
Life Insurance
Personal Injury
Retail
Outplacement
Career Transition
Career Services
Workshops
HR Consulting
Recruitment Services
Service Offering
Flourish
Optimise
Pathfinder
Thrive
Encore
Inspire
Empower
Other
N/A
Type of Service
Select Job Goal
SES (Same Employer - Same Job)
SEN (Same Employer - New Job)
NES (New Employer - Same Job)
NEN (New Employer - New Job)
Workplace Facilitated Discussion
SJSS (Specialised Job Seeking Services)
Other
Type of Referral
*
Job Seeking
Work Preparation
Single Services
Assessment
Work Status Code
01 : Working - Same Employer - Full Capacity
02 : Working - Same Employer - Current Work Capacity
03 : Working - Different Employer - Full Capacity
04 : Working - Different Employer - Current Work Capacity
06 : Not Working - Has no Current Capacity
08 : Not Working - Has Current Capacity
09 : Not Working - Not Entitled to Weekly Benefits
10 : Not Working - Retired
Cost Code
OR01
OR02
OR03
OR04
OR20
OR21
OR30
N/A
Pilot
Pilot
No
Pilot
Yes
Pilot Name
*
Injury Details
Claim Type
*
Select Type Of Claim
Physical
Psychological
Physical/Secondary Psychological
N/A
Nature of Injury
*
Medical Restrictions
*
Current Capacity (Hours)
*
*
Injury Note
*
Injury Date
Day
*
*
*
Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Year
*
*
*
Rehabilitation
Provider
*
Consultant First Name
*
Consultant Last Name
*
Email
*
*
Phone Number
*
Qualifications
*
Document
Authority to Exchange Information
*
Authority to Exchange Information
No
Authority to Exchange Information
Yes
Referral Note
*
Attachments
Upload Files
