Preferred Provider Form

I would like to nominate Recovery Partners as a preferred rehabilitation provider for the following states/territories:

"*" indicates required fields

Comments

This field is for validation purposes and should be left unchanged.

I am aware that as an employer I have the right to choose my preferred rehabilitation provider and I would like to nominate Recovery Partners.

State*

VIC

NSW

QLD

ACT

TAS

All states/territories

Contact Name on Policy

Policy Number

Company Name*

ABN*

Nominated Contact Name

First Last

Nominated Contact Title*

Phone

Email*

Signature*

Date of Agreement*