RTW Consent Form RTW Consent Form First Name*Last Name*Emergency Contact First and Last Name*Emergency Contact Phone Number*Consent* 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.DoctorSpecialistEmployer/Employer RepresentativeBrokerInsurerPhysiotherapistExercise PhysiologistPsychologistOtherOtherI 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 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 / Same Employer Same Job / New Employer Similar Job / New Employer New Job / New Employer Signature*Date* DD slash MM slash YYYY SignatureDate DD slash MM slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
