Online Referral Form – Medibank

Please complete the referral form below and a representative from IPAR will make contact with you.

Sections marked with an asterix* are required fields.

Step 1 of 3

Medibank Rehabilitation and Case Management details
Referrer name*
Referrer role*
Referrer email address*
Referrer phone number
Service/s required
Occupational rehabilitation services
- Accessibility Assessment
- Brief Ergonomic Assessment
- Early Intervention Return to Work Assessment
- Follow Up Module
- Return to Work Rehab Program
- Section 36 Rehabilitation Capacity Assessment
- Comprehensive Ergo Assessment
- Mental Health Review
- Remote/Virtual Ergonomic Assessment

Employee details
Employee name
Employee role
Claim number
Employee phone number
Employee date of birth
Date Format: DD slash MM slash YYYY
Employee email address
Employee work address
Employee gender
Is an interpreter required?
Which language do you require a translator for?
Injury details
Date injury occurred
Date Format: MM slash DD slash YYYY
Nature of injury
Employment information
Return to work status
Business entity*
Medibank employer details
Leader name
Leader role
Phone number
Employer location address
Email address

Any other information or instructions?
Where should we send the invoice?
Please upload any supporting documents here

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