SMHS Early Intervention Form

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.

Employee Reference Number

Injury Details

Injury

Date Of Injury

DD/MM/YYYY

Background Information

Injury Management Advisor/Representative Details

Full Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (+61) 0000-000-000.

Email (a confirmation email will be sent to this address)

example@example.com

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.

Preferred Date

Date

AM or PM? Choose all that apply.

Choose Your Required Clinic

Additional Comments/Notes

Services Requested For SMHS (Select Multiple If Appropriate)

SMHS Pre-Approved Guidelines Include:

Doctor

• Initial consult and 1 progress consult automatically approved
• Phone call to IMA required post initial review
• Initial medical imaging (X-Ray or Ultrasound) - requires approval from IMC
• Internal referrals to physio and OT are allowed
• Medical certificate to be provided for all consultations (Workcover if work- related, Fitness for Duty if non-work related)
• If additional services are required, contact the IMA to discuss

Physiotherapy and Occupational Therapy

• Initial consult and 1 follow appointment are approved
• Report to be provided after each session (refer to notes below)
• No consumables are pre-approved, call IMA if required
• If additional services are required, contact the IMA to discuss

Important Notes: Approved email addresses for reporting:

Fiona Stanley Hospital: fsh.injurymanagement@health.wa.gov.au
Fremantle Hospital & Health Service: FHHS.InjuryManagement@health.wa.gov.au
Rockingham General Hospital: RGH.InjuryManagement@health.wa.gov.au
Peel Health Campus: PHC.IM@health.wa.gov.au

Relevant Documents/Reports

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 weekly 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.

South Metro Health Services Early Intervention Referral