Authority to obtain information
For general authority, please tick the box/es provided.
The aim of your return to work service provider (the provider) is to assist
you to return to and/or remain in suitable employment and/or assist you
To limit authority, do not tick the box/es. Instead, write the names
to achieve re-integration into the community. In addition to speaking with
of people/ organisations you are authorising on the dotted line/s.
your case manager, they may need to discuss confidential information
You may also choose a combination of general and limited authority.
relevant to your injury with your doctor, medical provider/s, employer and
Assessing and treating medical doctors
in some instances other people/organisations and obtain information
from them. By completing this authority to obtain information (the
authority) you are giving your provider permission to obtain information
Assessing and treating medical providers (e.g. physiotherapist)
relevant to your return to work activity.
I (please print):
Pre-injury employer representatives
claim number (if known):
authorise my provider (specify organisation):
to obtain information relating to my injury/illness (specify):
sustained at work on or about (date): ____ / ____ / ______
from the following people/organisations I have indicated
Other (e.g. union representative, community organisations)
to the right to assist in the management of my recovery
and/or return to work.
I approve a copy of the authority, including an electronic version, being
treated as the original. The authority is valid for the duration of my claim
unless it is superseded by a new authority or until such time as either I,
or my representative, revoke the authority.