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Online Referral Form – Telstra

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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 4

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Telstra Rehabilitation and Case Management details
Rehabilitation delegate name*
Rehabilitation delegate email address*
Rehabilitation delegate phone number
Claims consultant name
Claims consultant email address
Claims consultant phone number

Service/s required
Single services assessments
- Simple Initial Assessment
- Comprehensive Initial Assessment
- Quick Check Workstation Assessment
- Comprehensive Workstation Assessment
- Vocational Assessment
- Brief Vocational Assessment with Job Seeking
Occupational rehabilitation services
- RTW Rehabilitation Services
- Follow up module (Early Intervention / non-Compensation)
- Progress report
- Closure report
- Other
Other

Employee details
Employee name
Claim number
Incident number
Employee phone number
Employee date of birth
MM slash DD slash YYYY
Employee email address
Employee home address
Employee gender
Is an interpreter required?
Which language do you require a translator for?
Injury details
Accepted injury/condition
Date injury occurred
MM slash DD slash YYYY
Other injury/condition
Employment information
Pre-injury hours per week
Current hours per week
Current duties
Certified capacity hours per week
Business unit*
Telstra employer details
Manager
Phone number
Email address
Work address

Treating doctor details
Treating doctor name
Treating doctor phone number
Treating doctor fax number
Treating doctor address
Do you need to add an additional treater?
Additional treater name
Additional treater speciality
Additional treater phone number
Additional treater fax number
Additional treater address
Rehabilitation plan/documentation details
Section 37 Rehabilitation plan required?
Current Section 37 Rehabilitation plan expiry
Suitable Duties plan required?
Current Suitable Duties plan expiry
Other required?
Other plan
Other plan expiry
Additional information

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