CMS Referral Form Date of Referral Case Manager Phone Number * Case Manager Name * Case Managers Email Address * Claimant Name ID * Claimant Mobile Number * Claim Number * Claimant Email * Claimant Address * PIAWE * Pre Injury Employer * Pre-Injury Role * Pre-Injury Earnings * Date of Injury * Current Employment Status * Select Agency * IFNSWParramatta IFNSWNewcastle IFNSWParamatta Team Early Intervention 1 Early Intervention 2 Tail 1 Tail 2 Ambulance [if description] IFNSWNewcastle Team Early Intervention 1 Early Intervention 2 Tail 1 Tail 2 Ambulance 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 Agency * Aboriginal Housing Office AG'S Ambulance Service of NSW Central Coast LHN Services Corrective Services DADHC Department of Family and Community Services DOCS E Health Family and Community Services Central Coast Government Workers Compensation Account Health Care Complaints Commission Health Support Services Hunter/New England Area Health Service Jenolan Caves Reserve Trust Justice Health Legal Aid Commission of NSW Lord Howe Island Board Mid North Coast LHN Services Ministry of Transport North Coast Area Health Service Northern LHN Services NSW Health Pathology NSW Maritime Authority Office of Environment and Heritage Protective Commissioner Rail Workers Fund Royal Rehab Roads and Maritime Services Sydney Ports Corporation Taronga Conservation Authority Other FACS New Option Agency Weeks Paid * 0 1-117 117-260 Medical Diagnosis * Capacity in hours a day * 0 1 2 3 4 5 6 7 8 Capacity in Days * 0 1 2 3 4 5 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: 500MB File Upload Drop a file here or click to upload Choose File Maximum upload size: 300MB Submit If you are human, leave this field blank. 2019-04-23
