WaterCorp Early Intervention Form

Patient / Injured Worker Details

Patient Full Legal Name

First NameLast Name

Patient Date Of Birth

DD/MM/YYYY

Injury Management Advisor/Representative Details

Full Name

First NameLast Name

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

example@example.com

Injury Details

Injury

Date Of Injury

DD/MM/YYYY

Relevant Information

Services Requested For WaterCorp (Select Multiple If Appropriate)

Would you like to add a Medical (Doctor consult) at the final appointment for a workers compensation medical certificate?

WaterCorp Pre-Approved Early Intervention Package Includes:

1 x initial assessment plus 3 x allied health sessions are approved.
Consumables up to a value of $100 are permitted with email or verbal approval.
A final email summary at the completion of the 3 sessions is to be sent to: workers.compensation@watercorporation.com.au

**Please note WaterCorp are opting to book their own patients in clinic, therefore the IMA does not need to be contacted for an appointment. Please attach this referral form to the patient file for therapist/GP reference.

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.

WaterCorp Early Intervention Referral