Rehabilitation Referrals

Online referrals for occupational rehabilitation made be submitted below.

Alternatively, you may download this form as pdf file. Download IM Referral Form.pdf

Please forward completed referral forms to:

Mail: PO Box 75, Orange NSW 2800

Fax: 1300 630 635

Should you require assistance please contact 1300 306 209, or email us and we will respond to your query as soon as possible.

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Insight Rehabilitation Referral Form

Case Type

Employer Details

Company:

Contact Name:

Address:

Phone:

Mobile:

Fax:

Email:

Insurer Details

Company:

Contact Name:

Address:

Phone:

Mobile:

Fax:

Email:

Patient Details

Name:

Address:

Phone (Work):

Phone (Home):

Mobile:

Fax:

Email:

Nominated Treating Doctor Details

Name:

Address:

Phone:

Fax:

Email:

Referral

Date:

Referred By:

Bill To:

Claim Number:

Occupation:

Employment Status:

Nature of Injury:

Date of Injury:

Date of Notification:

Interpreter Required:

Attachments

Claim Form:

Medical Reports:

Assessment Reports:

Medical Certificate:

Additional Comments: