Fillable Authority To Obtain Information Form printable pdf download

Authority To Obtain Information Form

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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):

Host employers

authorise my provider (specify organisation):

Potential/new employers

to obtain information relating to my injury/illness (specify):

Training organisations

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unless it is superseded by a new authority or until such time as either I,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.

Signature

Date

Authority To Obtain Information Form

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