Referral for Injury Management Services

Actevate Pty Ltd  WorkCover Provider No. 514

Three easy options to refer an injured worker:

• Call us on  1300 669 552;
• Click here to download our referral form; or
• Fill in this online form

Injured Worker		Injury Details
Injured Worker Surname		Date of Injury
First Name		Occupation
Address		Type of Injury
Phone		Claim Number
Date Of Birth		Selected Duties Yes No Unknown
Interpreter: Yes   No
Language
Status FT PT CAS AT WORK OFF WORK
Cease Date
Termination Date
Employer		Insurance Company
Employed By		Insurer
Address		Address
Phone		Phone
Fax		Fax
Employer Email		Email
Return To Work Coordinator:		Contact
Supervisor		Liability Status     Accepted    Denied    Unknown
Reason for Referral		Treating Doctor
Case Management Pre-Placement Health Ax Psychological Counselling Ergonomic Assessment Workplace Assessment Psychological Assessment Functional Assessment Employee Assist Program Vocational Assessment Rehabilitation Counselling Immediate Intervention Workplace Related Activities Job Seeking Rehabilitation Counselling		Doctor Name
		Doctor Address
		Doctor Phone
		Doctor Email
Comments
Referrer More Details		Insurance Broker
Referrer Surname:		Broker Company Name
Referrer First Name:		Broker Contact Name
Date:
Referral Email Address:
Referrer Company:
Image Verification: