ALLIANZ REFERRAL Exercise Physiology for Physical Injuries Allianz Referral Form "*" indicates required fields Injured Worker/ClientName* First Last Email* Phone*Address* Street Address City / Suburb State Postcode Date of Birth* Day Month Year Date of Injury* Day Month Year Interpreter required?* Yes No Language*Nominated Treating Doctor / GPDoctor/GP Name* First Last Email* Doctor/GP Phone*Doctor/GP Fax*Doctor/GP Address* Street Address City / Suburb State Postcode Allianz Case ManagerAllianz Case Manager Name* First Last Case Manager Email* Case Manager Phone*Allianz Injury Management AdvisorAllianz Injury Mgmt Advisor Name* First name Last name Mgmt Advisor Email* Mgmt Advisor Phone*Work StatusAbility to work* Unfit <15 hours capacity >15 hours capacity Current working status* Working Not working Current work attachment status* Job detached Job attached DocumentationDocuments provided via upload Work Cover COC Physiotherapist AHRR Rehab Provider Upload document(s) here* Drop files here or Select files Accepted file types: pdf, jpg, gif, png, Max. file size: 32 MB. Funding Approval ProvidedSpecialised Health Service MenuOptions EPA 001 Initial assessment +AHTR 1 EPA 006 Telehealth MCC (30 Mins EPA 002 Subsequent consultation weekly x 4 EPA 006 Telehealth MCC (30 mins) EPA 002 Subsequent weekly consultation x 4 EPA 005 Incidental expenses / membership (3mth max) EPA 006 Fortnightly updates to all stakeholders EPA 006 End of Program Telehealth MCC or Final Report Total Note: travel costs are billed and added as reasonably necessary at 78c per km. AHTR#2 will be considered at completion of Ahtr #1 if work capacity not achieved if deemed "High complexity Case" (OMPQ>50) during initial assessment approval will be requested for EPA009 costs.Consent for Specialised Health to undertake these servicesName* First Last Signature*PhoneThis field is for validation purposes and should be left unchanged.
