Silverchain 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

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

Preferred Clinic Location

Additional Comments/Notes

Services Requested For Silverchain (Select Multiple If Appropriate)

Silverchain Pre-Approved Early Intervention Package Includes:

Patient needs to be called directly to book in appointment/s.
Up to 3 x physiotherapy sessions. Contact IMA to discuss if extra sessions are required.
Functional Capacity report to be completed by the doctor (unless the doctor thinks the patient will be unable to recover in 3 weeks/3 physiotherapy sessions, then WC certificate may be provided).
Consumables: None unless prior approval from IMA.
No reports/formal communication required. Preference for physiotherapist to email IMA when worker is deemed fit.

Relevant Documents/Reports

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

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.

Silverchain Early Intervention Referral