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Organisation Details
Insurer / Organisation Name
*
Branch / Division
*
Organisation's Phone Number
Organisation's Email Address
Contact / Case Manager's Name
*
Contact's
Phone Number
*
Contact's
Email Address
*
Contact's Role
Contact's Team Name
Preferred CMS Consultant
Rehab Provider Details
Rehab Provider Organisation's Name
Rehab Provider Organisation's Branch / State
Rehab Consultant's Name
Rehab Consultant's Phone Number
Rehab Consultant's Email Address
Claimant Details
Case Number
*
Date of Notification
Claimant's Name
*
Claimant's Phone Number
*
Claimants Email Address
*
Street Address
*
Suburb
*
State
*
Post Code
*
Claimant's Date of Birth
*
Claimant’s Employment
Claimant's Pre-Injury Role
*
Claimant's Pre-Injury Employer
Employer Location
Current Employment Status
Pre-Injury Average Weekly Earnings
*
Pre-Injury Hours
*
Case Details
Legal Involvement
CMS Service Offering Product
*
Case Details - CMS Service Offering Product
Flourish
Early Intervention Career Coaching
Optimise
Job Seeker Specialist Career Coaching
Pathfinder
Work Preparation / Compliance / MOL
Kick Start
Fixed Package - 4 Weeks
Jump Start
Fixed
Package
- 8 Weeks
Single Services
Other
Unsure
Type of Service / Return to Work Goal
Type of Assistance Required
*
Is this a pilot?
Case Details - Is this a pilot
A
Yes
B
No
Injury Details
Claim Type
*
Nature of Injury
Medical Restrictions
Current Capacity (Hours)
*
Date of Injury
Injury Notes
Other Provider Details
Other Provider
Other Provider Consultant Name
Phone Number
Email
Documents
Authority to Exchange Information
*
Documents - Authority to Exchange Information
A
Yes
B
No
Referral Notes
Attachments
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Size limit: 100 MB
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