COMPASS 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.

Injury Details

Injury

Date Of Injury

DD/MM/YYYY

Background Information

Injury Management Advisor/Representative Details

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.

Western Australia or Queensland?

WA Clinics

QLD Clinics

Additional Comments/Notes

Services Requested For COMPASS (Select Multiple If Appropriate)

Would you like to add a Medical (Doctor consult) to your request?

Number of doctor consults approved (including initial assessment)?

Please Select The Medical Certificate type required for the consult.

COMPASS Pre-Approved Early Intervention Package Includes:

3 x Physiotherapy or OT (Hand Therapy) sessions.
Phone call requested after each session.
If patient is cleared for full duties throughout treatment, email to be sent to IMA to advise.
If patient is not cleared for full duties by the end of the treatment period, email to be sent to the IMA outlining restrictions and ongoing recommendations.
Consumables = maximum $150.00, approval required via phone or email for anything above this amount.

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 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.

COMPASS Early Intervention Referral