Referral: Comcare Step 1 of 6 - Referrer's & Insurer Details 0% Referrer's DetailsCompany NameTitle*Name* First Last Street Address* Street Address Address Line 2 City State Post Code Postal Address* Referrer's postal address the same as street address? Street Address Address Line 2 City State Post Code Phone*FaxEmail* Are you paying for this service?* Yes No Insurer's DetailsCompany NameTitle*Name* First Last Street Address* Street Address Address Line 2 City State Post Code Postal Address* Insurer's postal address the same as street address? Street Address Address Line 2 City State Post Code Phone*FaxEmail* Is this Insurer aware of this referral?* Yes No FaxEmail* Claimant's DetailsName* First Last Street Address* Street Address Address Line 2 City State Post Code Phone*FaxEmail Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Does the Claimant require an Interpreter?* Yes No What is the Claimant's Preferred Language?* Claimant's Work DetailsOccupation*Classification*PIHAverage Weekly Earnings*Type of Employment* Full Time Part Time Casual Contract Current working hoursInclude the total number of hours that the employee is currently working.Current certified capacityAs indicated on the certificate of capacity.Is the Claimant currently on weekly benefits?* Yes No How much is the Claimant currently being paid?Claimant's Injury DetailsDate of Injury*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Injury Type*Claim Number*Has the insurer accepted liability?* Yes No Are the Employers Details the same as the Referrer's?* Yes No Unknown Employer's DetailsCompany Name*Title*Name* First Last Street Address* Street Address Address Line 2 City State Post Code Postal Address* Insurer's postal address the same as street address? Street Address Address Line 2 City State Post Code Phone*FaxEmail* Treating Practitioner's DetailsTitleName* First Last Practice Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*FaxEmail Services Required* Section 36 Ax Rehab program ADL Other Please Specify*Expected Outcomes and CommentsWhat do you expect from the above servicing?*Additional Comments? Yes No Additional Comments*Approved CostsExcluding GST*DocumentationFile upload Drop files here or Select files Accepted file types: pdf, tiff, doc, docx, xls, xlsx, jpg, png, Max. file size: 50 MB. Please upload any documentation to support your referral (to a maximum of 8MB total).CAPTCHA Δ
