Information Consent Form

Name
This field is for validation purposes and should be left unchanged.
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:
Doctor
Specialist
Employer
Broker
Insurer
Physiotherapist
Exercise Physiologist
Psychologist
Other
Other
Other
- 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*
Name of Interpreter (If Applicable)
Signature (Interpreter - If Applicable)
Date