CMS + Change Room Referral Form Enhance Program Referring Organisation * QBE EML GIO TAL Allianz iCare Other Referring Organisation Agency / NSW Team Other Ambulance Correctives NNSW LHD Select Agency Case Manager Name * Case Managers Email Address * Case Manager Phone Number * Date of Referral Claimant Name * Claim Number * Claimant Phone Number * Date of Birth Claimant Address * Claimant Email * Capacity in hours a day * 0 1 2 3 4 5 6 7 8 Capacity in Days 0 1 2 3 4 5 Work Status Code * 06 - Not Working No Current Capacity 08 - Not Working Has Current Capacity 09 - Not Working Not Entitled To Weekly Benefits 10 - Not working - Retired ( Weekly Payments Ceased Due To Retirement Limitation) 04 - Working - Different Employer - Current Work Capacity 03 - Working - Different Employer - Full Work Capacity 02 - Working Same Employer - Current Work Capacity 01 - Working - Same Employer - Current Work Capacity Current Average Weekly Earnings * Weeks Paid * O - 13O - 13 13 - 104 104 + Date of Injury Nature of Injury Is Individual more than 20% whole person Impaired How Injury Occured Current Medical Restrictions Are the restrictions expected to change? Yes No Timeframe 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 38+ Pre Injury Employer Pre-Injury Role Pre Injury Hours 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 38+ Pre Injury Earnings * Current Employment Status Attached Detached Is Voc Rehabilitation Provider Active on File? Yes No Not Sure Voc Rehabilitation Company Name * Rehabilitation Consultant Name * Rehab phone * Rehabilitation Email Has Voc Assessment Been completed? Yes (Please Attach) No Not Sure Is the client legally represented? Not Sure Yes No Wellbeing & RTW Readiness 1 2 3 4 5 6 7 8 9 10 Select the CMS+CHANGE ROOM type of service Live Connect Not Sure CMS + CHANGE ROOM Virtual Choose Location Sydney Newcastle NNSW Choose Location Notes Upload file Drop a file here or click to upload Choose File Maximum upload size: 500MB File Upload Drop a file here or click to upload Choose File Maximum upload size: 300MB File Upload Drop a file here or click to upload Choose File Maximum upload size: 300MB Preferred Career Consultant Submit Δ 2020-10-09
