CMS QBE Referral Form Canberra Date of Referral Canberra Team Early Intervention 1 Early Intervention 2 Tail 1 Tail 2 Case Manager Name * Case Managers Email Address * Case Manager Phone Number * Claimant Name * Case Number * Claimant Address * Claimant Phone * 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 Average Weekly Earnings * Weeks Paid * 0 - 26 27 - 38 38+ Date of Injury Medical Diagnosis How Injury Occurred Current Medical Restrictions Are Restrictions Expected To Change? If yes, Please state time frame Current Employment Status Pre Injury Employer Role Title at the time of Injury Pre injury hours: Pre-Injury Earnings Is Voc Rehab Provider Active on File Yes No Voc Rehab Provider (Organisation) Rehab Consultant Rehab Consultant Phone : Rehab Consultant Email: Has Voc Assessment Been Completed? (If yes please attach.) Yes No Upload file Drop a file here or click to upload Choose File Maximum upload size: 134.22MB Is the client Legally Represented? Yes No Select Type of Service Job Seeking Single Service Other Select Type of Service Rehab Partnership Yes No Other Notes or Comments File Upload Drop a file here or click to upload Choose File Maximum upload size: 134.22MB File Upload Drop a file here or click to upload Choose File Maximum upload size: 134.22MB Submit If you are human, leave this field blank. 2019-08-11
