Referral of Injured Worker to HPOM

***Completion & submission of this electronic referral form generates critical email alerts***

IMPORTANT:

Click on the link below and read the webpage it leads to, before continuing:

The page linked above contains important information relating to the service. If you are unfamiliar with the points therein, it may cause unecessary delay in getting your injured worker attended to.

Tick if you have read and understand the information on the page linked *

IMPORTANT!!!

PLEASE SELECT ONE OF THE BELOW ANSWERS

** Ensure the final option is selected only if none apply**

IMPORTANT!!!!

STRONGLY CONSIDER ARRANGING FOR URGENT TRANSFER OF THE WORKER TO THE LOCAL EMERGENCY DEPARTMENT (000 ETC.) IF YOU HAVE SELECTED ANY OF THE ABOVE

SERVICE REQUESTED & DETAILS OF REFERRING ENTITY

How quickly would you like the appointment to take place?

URGENT - ASAP/ within 2 - 3 hours if possibleLESS URGENT - But within 4-6 hours if possibleLESS URGENT - Can wait until HPOM usual opening hours - Monday - Friday 8am to 5pm (AEST)

Remember, no Dr. available after 10pm and up to 7am

REMEMBER !!! Make sure you call 02 9159 3711 with all referrals, and particularly when outside of usual hours!!!

DO NOT depend on this form as the sole means of communicating the referral to the HPOM team!!!

TIMES THAT A DOCTOR WILL NOT BE AVAILABLE:

After 10pm - 7 days per week

Before 7am - 7 days per week

Sunday and Public Holidays coverage cannot be guaranteed

What is the reason for this referral? *

DOCTOR APPOINTMENT: Early intervention consultation (no claim, but issue please COC to employer)DOCTOR APPOINTMENT: Early intervention consultation (no claim, issue please a brief report to employer)DOCTOR APPOINTMENT: Worker's comp case (with issue of COC to employer +/- injured worker)PHYSIO APPOINTMENT: Request for telehealth Physiotherapy (HPOM network)

COC = Certificate of capacity

Requested location (or means) of assessment: *Face-to-face appointments available in HORSLEY PARK clinic: Mon - Fri 08:00 - 17:00 / Telehealth 07:00am - 10:00pm daily

Employer (Company) of injured worker: *

Name of individual completing this form: *

Enter your email address below: *Enter you email address here to receive an automated reply with further instructions

What is your role? *

RTW /HR officerRehab consultantSpecialist Dr.GP

Please enter your relevant details here (Phone #, relationship to the case etc.):

DETAILS OF WORKER & THEIR INJURY

CONSENT - Are they aware that this referral is being made? *

YesNoNot sure

It is YOUR RESPONSIBILITY to ALWAYS seek & DOCUMENT that you have gained an appropriate level of consent to share a worker's details with us

Date of injury:Please enter if you know the date of injury

If unsure, can you estimate when the injury may have occurred?

Are you uploading your own referral document? *

YES - I am uploading our own referral containing worker name and contact detailsNO - I wish to enter worker name on contact details manually on this form

Upload your worker's details *

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This should contain (at least) name & contact details of your injured worker. Import a file or take a photo of the document (Max. file size 7MB)

First name of candidate/ injured worker: *

Surname of injured worker: *

DOB:

Address:Enter address of injured worker if you know it

Suburb:

PHONE CONTACT DETAILS FOR INJURED WORKER: *10 digits only i.e. enter the number without spaces - If this is unknown, please enter the same digit 10 times e.g. 2222222222

Which of the following sections do you wish to complete?

Care to date & planned careRelevant uploadsFurther/ additional information about the injury/ injuries

Further/ additional information = mechanism, location and other relevant details about the injury

1. Care to date

2. Planned care

Tick here if you wish to skip this section

Has the worker already had medical review for this problem?

NOYES

AHP = Physiotherapist, Psychologist etc.

Details - Medical provider/sOptional to complete

Has the worker already seen or has a referral already been made to an AHP? *

NO - not seen nor been referred to an AHPYES - they have started seeing an AHPYES - they have been referred to an AHP provider and are awaiting the first appointment

AHP = Physiotherapist, Psychologist etc.

Details - AHPOptional to complete

Date book for next Allied Health review (if known)

Relevant uploads

Tick if you wish to upload clinical information:

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Do not upload without obtaining (and recording) consent of worker

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Do not upload without obtaining (and recording) consent of worker

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Do not upload without obtaining (and recording) consent of worker

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Do not upload without obtaining (and recording) consent of worker

Further/ additional information about the injury/ injuries

The below sections are helpful to complete but nevertheless OPTIONAL

Tick here if you wish to provide further details regarding: MECHANISM OF INJURY

Tick here if you wish to provide further details regarding: NATURE OR LOCATION OF INJURY (OR INJURIES)

Tick here if you wish to DEMONSTRATE LOCATION OF INJURIES ON A DIAGRAM

Nature or location of injury (or injuries):

Mechanism of injury:

Clear drawing

Any further file upload:

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You can upload any (appropriate) clinical images or other useful information here (obviously with the appropriate consent having been obtained)

SO LONG AS YOU HAVE ENTERED YOUR EMAIL ADDRESS CORRECTLY (ABOVE), ON SUBMISSION YOU WILL RECEIVE A CONFIRMATION MESSAGE WITH FURTHER INSTRUCTIONS INCLUDING USUAL HOURS, CONTACT NUMBERS ETC.

FINALLY! Please advise HPOM if you wish us to make amendments to your bespoke corporate referral form; among other facilities, this can generate automated correspondence to nominated company representatives at any particular sites

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