Early Intervention Referral Form

  • Early Intervention Referral Form

  • Company / Employer Details

  • Click on this link to continue filling out the MRL referral form.

  • Click on this link to continue filling out the Civeo referral form.

  • Click on this link to continue filling out the Westrac referral form.

  • Click on this link to continue filling out the Watercorp referral form.

  • Click on this link to continue filling out the Crown referral form.

  • Patient / Injured Worker Details

  • Format: (+61) 0000-000-000.

  • Injury Details

  • Early Intervention Services

  • Services Requested (Select Multiple if appropriate)*
  • Reporting Requirements (PT, OT, PSYCH) Please select the level of reporting required and the preferred form of communication throughout the early intervention program.*
  • Reporting Requirements (EP) Please select the level of reporting required and the preferred form of communication throughout the early intervention program.*
  • Please select your preferred Communication Method for session updates*
  • Do you approve cost of consumables if required? e.g. splint/brace etc.*
  • Would you like to add a Medical (Doctor Consult) to your request?
  • Please select the Medical Certificate type required for the consult
  • Are referrals for additional services approved under the referral (e.g. specialist, allied health, psychology)?
  • Please select the investigation services approved under the referral*

  • Please provide your preferred appointment requirements.

    We will endeavour to schedule the next closest available day and time to suit your preferences and will email you with the appointment details once confirmed.

  • AM or PM? Choose all that apply.
  • Western Australia or Queensland?
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  • RediMed Early Intervention Pricing & Billing

  • RediMed WA Early Intervention Pricing
  • RediMed WA Early Intervention Pricing
    • If multiple discipline services are required, costings will be as per each allied health service separately.
    • GP/Medical Consult: Aligned to state-based Workers Compensation gazetted rates
    • Quoted costs are inclusive of all consultation, communication and report costs, if service is not provided, total cost will decrease. The total cost of the program will not exceed the quoted price, exclusive of any approved consumables funding 
    • Invoicing is completed following each session and will be itemised with consult, communication and consumables 
    • If a final report is requested, cost is additional  
    • Prices are exclusive of GST 
  • I have read the Pricing Structure of RediMed's Early Intervention Program and understand, agree and consent to the associated fee schedule.

  • 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/

     

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