Work Cover / CTP Referral Form : Join the One Tribe Family

Complete Our Work Cover / CTP Referral Form

We value every single referral, and promise to provide the highest quality of care to each individual that we work with. Please fill out the below details as best as possible so that we can promptly action your referral.

Goals of Referral / Purpose of Referral

Worker Gender

Worker First Name(Required)

Worker Last Name(Required)

Worker Date of Birth

Worker Phone Number

Worker Email

Worker Address

Claim Number

Diagnosis

Date of Injury

Other Health Conditions

Nominated Treating Doctor Practice Name(Required)

Nominated Treating Doctor First Name(Required)

Nominated Treating Doctor Last Name(Required)

Nominated Treating Doctor Phone Number

Insurer Company Name

Case Manager First Name

Case Manager Last Name

Case Manager Phone

Case Manager Email

Rehabilitation Provider Company Name

Rehabilitation Consultant First Name

Rehabilitation Consultant Last Name

Rehabilitation Consultant Phone Number

Rehabilitation Consultant Email

Employer Company Name

Employer Contact First Name

Employer Contact Last Name

Employer Contact Phone

Employer Contact Email

Other Comments

Communication preferences, preferred appointment times, type of program preferred, other stakeholders involved, general comments

Upload Relevant Supporting Documents

Certificate of Capacity, Scans, Specialist/GP/Allied Health Practitioner reports, Return to Work Plans, Job Task Analysis/Workplace Requirements etc.

Drop files here or

Max. file size: 256 MB.

Work Cover / CTP Referral Form

Complete Our Work Cover / CTP Referral Form

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