Medical Information Consent Form Medical Information Consent Form "*" indicates required fields PhoneThis field is for validation purposes and should be left unchanged.First and Last Name*• Voluntarily accessed through Recovery Partners Injury Reporting Centre • Lodged a workers compensation claim • Sought assistance with managing a medical condition* I authorise and consent to the collection, disclosure, and release of my personal and health information by any person who provides a medical service or hospital service to me in connection with an injury/condition to which I have:• Voluntarily accessed through Recovery Partners Injury Reporting Centre • Lodged a workers compensation claim • Sought assistance with managing a medical condition• The management of your rehabilitation/Return to Work plan • Classification of injury within bp • To facilitate a safe return to work • Provide any on-going workplace support services as required • Preventing further injuries* I further consent and understand that the personal information collected may be used for the following purposes in relation to this injury:• The management of your rehabilitation/Return to Work plan • Classification of injury within bp • To facilitate a safe return to work • Provide any on-going workplace support services as required • Preventing further injuriesSignature*Date* Employee Number*Claim Number (if known):
