Worklink - Voc Rehab Referral (VR1)

Worklink's services aim to decrease the economic and human cost of work related injury and illness

Vocational Rehabilitation Referral Form (VR1)

WorkCover Provider No: 037

WORKER'S DETAILS

Mr/Mrs/Miss/Ms	Invalid Input
Surname	Invalid Input
Other Name(s)	Invalid Input
DOB	Invalid Input
Address	Invalid Input
Telephone No.	Mobile
Occupation
Interpreter Required?	YesNo Invalid Input
INSURANCE DETAILS
Claim Number	Invalid Input
Date of Injury	Invalid Input
Injury Type	Invalid Input
Insurer	Invalid Input
Insurer Contact	Invalid Input
Contact Tel No.	Invalid Input
EMPLOYER DETAILS
Company Name	Invalid Input
Company Address	Invalid Input
Telephone	Invalid Input
Contact Name	Invalid Input
MEDICAL PRACTITIONER DETAILS
Dr's Name	Invalid Input
Practice Name	Invalid Input
Address	Invalid Input
Telephone	Invalid Input

REFERRER'S DETAILS
Referring Source (*)	Treating medical practitioner Employer Insurer on behalf of employer Invalid Input
Referrer Name (*)	Invalid Input
Referrer Email Address (*)	Invalid Input
Referral Type	Invalid Input
Specific Service	Functional Capacity Assessment Ergonomic Assessment Job Demands Assessment Workplace Assessment Other Invalid Input
Discussion:	I have discussed this referral with the worker and they are in agreement. Invalid Input
I have discussed this referral with:	EmployerTreating Medical Practitioner Invalid Input
	(If repeated attempts at contacting the other party have been unsuccessful, please contact the Injury Management Review Unit at WorkCover WA on 9388 5555)
"FLAG" Strategy	Invalid Input(Worklink Long Tail Claims Strategy)
Comments	Invalid Input
Print Form
Enter Code	Refresh Invalid Input