Information Consent Form Information Consent Form I authorise Recovery Partners to obtain and release information regarding my injury with the nominated people below to ensure a safe and durable return to work:DoctorSpecialistEmployerBrokerInsurerPhysiotherapistExercise PhysiologistPsychologistOtherOtherOther- I understand that this information will only be discussed with the people mentioned above and that all information gathered will be held in the strictest confidence.- The scope of this authority to release medical and personal information is limited to the related injury only.- I understand that I may withdraw or amend this authority at any time. I agree with an interim rehabilitation goal of:* Same Job / Same Employer Similar Job / Same Employer New Job / New Employer Same Job / New Employer Similar Job / New Employer New Job / Same Employer Name*Signature*Date* DD slash MM slash YYYY Name of Interpreter (If Applicable)Signature (Interpreter - If Applicable)Date DD slash MM slash YYYY EmailThis field is for validation purposes and should be left unchanged.
