Authority To Obtain Information Form Page 2
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1
2Instructions for completing the Authority to obtain
6. A copy of the completed and signed authority must be provided to the:
information
• worker
The Return to work service provider must arrange for this authority to be
• case manager
completed and signed by the worker prior to any information of a
• employer or employer representative/s
confidential nature being obtained in relation to the worker’s recovery and
• people/organisations authorised by the worker
return to work. It is important the worker be provided assistance to fully
to release information to the provider
comprehend the purpose and use of the authority and offered assistance
Note: It is necessary to provide a copy of the authority to the worker’s
to complete the Authority to obtain information form (the form). Further
pre-injury employer only if the worker is still employed by that employer.
information may be obtained from ReturnToWorkSA on 13 18 55.
7. A copy of all completed and signed authorities are to be kept together in
1. The worker has the right to seek independent advice before signing
a prominent position on the return to work services file and forwarded
the form. This is not a prescribed form and therefore the worker has
to relevant people/organisations as required. If there is more than one
the right to alter the form or provide an alternative authority.
return to work services file for the worker, a copy of the most recent
authority is to be kept on each file.
2. Involvement of a representative of the worker should occur only
if requested/authorised by the worker.
8. This form is available in several common languages at
If an interpreter is used for completing the authority, please ensure the
3. Prior to obtaining confidential information, providers must ensure
Interpreter declaration form is also completed and attached to the
the authority is valid (e.g. has not been revoked by the worker) and
authority. For a copy of the form and guidelines please contact
the information is relevant to the management of the worker’s recovery
ReturnToWorkSA on 13 18 55.
and/or return to work.
9. The provider has forwarded copies of the authority to the following
4. In relation to the worker approving people/organisations involved in
people/organisations on the dates noted:
their recovery and/or return to work, they are to:
Worker
___ / ___ / _____
1) either tick the box provided or leave the box blank and specify
names if choosing to limit authority (e.g. Dr Adam X or Y’s Medical
Case manager
___ / ___ / _____
Centre); and
2) tick or specify only relevant people/organisations as not all will
___ / ___ / _____
be relevant to the worker’s recovery and/or return to work.
___ / ___ / _____
5. If changes are made to people/organisations involved in the worker’s
recovery and/or return to work, the worker is to be asked to sign a
___ / ___ / _____
new authority. Once signed, the latest authority will automatically
supersede the previous authority. Therefore it is essential that the
___ / ___ / _____
new authority include all previously listed people/organisations,
if still relevant.
ReturnToWorkSA
To contact ReturnToWorkSA in a language other than English,
please ring the Interpreting and Translating Centre on 1800 280 203
GPO Box 2668
and ask them to contact us on 13 18 55.
South Australia 5000
This interpreting service is available at no cost to you.
If you need any information in braille, audio, e-text or large print,
Phone: 13 18 55
please call us on 13 18 55 and we will do our best to help you.
Fax: 08 8238 5775
If you are deaf or have a hearing or speech impairment you can
call ReturnToWorkSA through the National Relay Service (NRS):
Email:
• TTY users can phone 13 36 77 then ask for 13 18 55.
Website:
• Speak & Listen (speech-to-speech) users can phone
1300 555 727 then ask for 13 18 55.
• Internet relay users can connect to NRS on
then ask for 13 18 55.
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