AUTHORITY TO OBTAIN AND RELEASE INFORMATION – CONSENT FORM

    RTW Rehab – Authority to Obtain and Release Information - Consent Form

    WORKER DETAILS (Required)

    CONSENT (Required)

    I,, give permission for RTW Rehab (Workplace Rehabilitation Provider, SIRA Number 335) to obtain and release medical and rehabilitation information from my Doctor(s), relevant Treating Health Professionals, Employer, Union (if applicable), and Insurer / Funder.


    I understand that this information will only relate to the injury for which I have been referred and will be regarded as totally confidential.

    Any photos we take of you and your activities and use in our reports will be de-identified, by blurring or concealing your face or any other identifiable or distinguishable markings.


    You are able to withdraw your Consent at any stage - please inform us should you ever choose to cease your Consent.

    NB: Some organisations are legally entitled to receive information about an Injured Worker who is claiming Compensation,
    i.e. Insurers and their Legal Representatives, the State Insurance Regulatory Authority (SIRA), a NSW Court of Law, and the NSW Workers Compensation Commission.

    STAKEHOLDERS

    Pre-Incident Employer

    Nominated Treating Doctor (GP)

    Nominated Treating Therapist (Physical Therapist, Psychologist, etc)

    Solicitor

    Union Representative

    Insurer