MRL Early Intervention Referral Form

Mineral Resources Early Intervention Referral
Patient / Injured Worker Details
Full Legal Name*

First NameLast Name
Patient Date Of Birth*
DD/MM/YYYY
Patient Email
example@example.com
Patient Phone Number*
Please enter a valid phone number.Format: (+61) 0000-000-000.
Injury Details
Injury*
Date Of Injury*
DD/MM/YYYY
Background Information
Injury Management Advisor/ Representative Details:*

Full Name

Phone Number

Email AddressNazione / Provincia

Email Address
Please provide your preferred appointment requirements.

We will endeavour to schedule the closest available day and time to suit your requirements and will email you with the appointment details once confirmed.
AM or PM? Choose all that apply.

AMPM
Western Australia or Queensland?

WAQLD
WA Clinics
QLD Clinics
Additional Comments/Notes
Services Requested For MRL (Select Multiple If Appropriate)

PhysiotherapyOccupational Therapy (Hand Therapy)Exercise PhysiologyPsychologyGP
Mineral Resources Pre-Approved Early Intervention Package Includes:
- 1 x initial session + 3 x subsequent sessions with;
  - Initial report
  - Final report at the final sessions
  - $3000.00 maximum approval for all services/consumables across the time the patient is in the Early Intervention program.
Relevant Documents/Reports

Cancelof
Please review both links below to our privacy policy prior to completing the form. https://www.redimed.com.au/privacy-policy/

https://www.redimed.com.au/terms-and-conditions/
- If multiple discipline services are required, costings will be as per each allied health service separately.
- All costings are aligned with the respective state-based Workers Compensation gazetted rates.
- Costs are inclusive of all approved consultations, consumables, communication and reports, in line with the state-based Workers Compensation gazetted rates.
- Invoicing is completed following each session and will be itemised with consult, report, communication and consumables
I have read the structure of RediMed's Early Intervention Program and understand, agree and consent to the associated early intervention package.

YesNo
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Mineral Resources Early Intervention Referral