Fast Online Referral Form

Your name*
First Last
Your email address*
Enter Email Confirm Email
Are you an…..
What service can we assist you with?*
Service required*
- Face-to-face
- Telehealth
Preferred IPAR Consultant request (please insert consultant name if known or leave blank)
What type of Medicolegal Assessment do you require?*
What is the client's suburb and state?*
When is the Assessment required?*
Client name*
Date of birth*
Claim number*
Return to Work - Same Employer*
- Yes
- No
Return to Work - Different Employer*
- Yes
- No
Date of Notification
DD slash MM slash YYYY
Nature of Injury*
Employer suburb (enter N/A if not employer attached)*
Please provide any additional information regarding the service required*
Client suburb*
Mediation participant 1*
Mediation participant 2*
Suburb where Mediation is required*
Postcode*
State*

Your Details
Company*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact telephone no*
Has the employer nominated IPAR as their preferred provider?
i
- Yes
- No
x
Nominating IPAR as your preferred provider means:
- Saving time and money as you will no longer need to brief a new rehabilitation provider when allocated to you by an insurance agent
- A strong understanding of your business by both IPAR and your company’s insurance case manager
- Development of the most ideal approach to cases, to facilitate more effective Return to Work planning and implementation
- Improved ability to track and monitor Return to Work progress and results over time
- A single point of contact for all matters related to rehabilitation, return to work and injury prevention
Nominating IPAR as your preferred provider is easy. Simply complete the online Provider Nomination form below and we will notify your insurance agent of your request.
If no, would the employer like to nominate IPAR as their preferred provider?
i
- Yes
- No
If yes, please complete our online Preferred Provider Nomination form or send an email to employerdirect@ipar.com.au

Is there any further information that you want to provide for this referral?
Preferred contact method
Has a Workcover or Comcare claim form been submitted?*
- Yes
- No
If Yes, please upload the S36 Referral form in the Supporting files area below.
Supporting files (up to 4 files can be uploaded)
Drop files here or

Max. file size: 200 MB.
Please upload any relevant supporting documentation. Accepted file types: doc, pdf, zip, rtf and xls. Maximum file size is 5MB. If more than 4 attachments, please add to zip file.
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