Section 5: Services requested Service type (include consultation type and Number of Frequency/timeframe Service code Unit Total other services eg aids/equipment) sessions (eg 1 x week for six weeks) (if applicable) cost/specify – If you wish to add another service type, right click on the last full row in the table and select rows below’. ‘Insert/Insert Case conferencing only Number of Frequency/timeframe Service code Unit Total (if applicable) cost/specify Case conferencing Overall total (total of all cells above) Workers compensation: Would you like the assistance of an Independent Consultant? Yes No Rationale for services requested (include/attach additional information to assist insurer decision making) Anticipated date of discharge (DD/MM/YYYY) Section 6: Service provider details Service provider name Practice name Suburb State Postcode Phone number Fax number SIRA (formerly known as WorkCover) Best time/day to contact workers compensation approval number (if relevant) All SIRA approved practitioners must ensure their contact details with SIRA Note: are up to date. Email your current details to Signature Provider stamp (if available)
Section 5: Services requested Service type (include consultation type and other services – eg aids/equipment) Number of sessions Frequency/timeframe (eg 1 x week for six weeks) Service code (if applicable) Unit cost/specify Total If you wish to add another service type, right click on the last full row in the table and select ‘Insert/Insert rows below’. Case conferencing only Number of Frequency/timeframe Service code (if applicable) Unit cost/specify Total Case conferencing Overall total (total of all cells above) Workers compensation: Would you like the assistance of an Independent Consultant? Yes No Rationale for services requested (include/attach additional information to assist insurer decision making) Anticipated date of discharge (DD/MM/YYYY) Section 6: Service provider details Service provider name Practice name Suburb State Postcode Phone number Fax number Best time/day to contact SIRA (formerly known as WorkCover) workers compensation approval number (if relevant) Note: All SIRA approved practitioners must ensure their contact details with SIRA are up to date. Email your current details to Signature Provider stamp (if available)
SIRA08033-AHRR-Word.docx