Workcover Patient Form

Please complete all of the details on the form and click the send button. If you do not supply the correct information, a confirmation of your appointment cannot be sent.

Please Complete the Following Form and Click Send


Your Name (person submitting form):		*
Your Email:		*
Appointment Date ( provided to you - dd/mm/yyyy ):		*
Surname:		*
Firstname (as listed on Medicare Card):		*
Middle Initial:
Title:
Preferred First Name (If different to Medicare Name):
Address - Street (including number):		*
Address - Suburb:		*
Address - Postcode:
Postal Address (if different to details above):
Date of Birth (dd/mm/yyyy):		*
Phone - Home:
Phone - Work:
Phone - Mobile:
Workers Compensation Insurance
Claim No. (if you have one):
Under which Workers Compensation Insurer are you covered?:	WorkCover Qld Comcare Employer Sponsored WorkCover Scheme Other	*
If other, what is the name of the scheme?:
Name of Case Manager (if known):
Email Address of Case Manager:
Referral Details
Doctors Firstname:
Doctors Lastname:		*
Practice Name:
Practice Phone Number:
Private Health Insurance and Medicare Details (in the case of claim rejection)
Do you have private hospital cover:	No Yes
Name of Health Fund:
Health Fund Membership Number:
Medicare Card Number:
Medicare Card Ref Number Item Prefix:
Confirmation
Please Note: Once your claim has been approved, all accounts will be sent directly to your WC Insurer. If your claim for compensation is rejected, you will be responsible for any fees. :	I have read and understand the fees and charges schedule and agree.	*

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