Online Referral Form

Please complete the form below and a representative from IPAR will make contact with you

Please note that by submitting this form to IPAR, you allow us to add your details to our database. Your details will not be passed on to any external businesses or third party without your consent. Please refer to our Privacy Policy and document disclosure information.

Don’t have time to complete our full online referral form? Try our shorter Fast Form for online referrals.

IPAR’s fast form requires only a minimal amount of referral information to be entered. Once you have submitted your fast form, an IPAR representative will contact you to gather all relevant referral information.

Sections marked with an asterix* are required fields.

Step 1 of 11

Are you an...*
Service required*
Service required*
- Face-to-face
- Telehealth
Please provide information on the type of service*
Preferred IPAR Consultant request (please insert consultant name if known or leave blank)

Business name*
Business address*
Street Address Address Line 2 City State Postcode Country
Type of business*
Your name*
First Last
Your role*
Other
Your contact number*
Your email*
Enter Email Confirm Email
Brief description for mediation referral*
Date or duration of dispute between participants*
Date or duration – business knowledge of issues*
Funding of mediation (% percentage)
Referrer Participant One Participant Two Other (specify)

Participant One
Name*
First Last
Role*
Contact number*
Email*
Enter Email Confirm Email
Work address*
Street Address Address Line 2 City State Postcode Country
Professional relationship of Participant One to Participant Two*
Mediation request or awareness*
Are there any special needs or culture needs that need to be considered? (e.g. interpreter etc)
Other relevant information
Participant Two
Name*
First Last
Role*
Contact number*
Email*
Enter Email Confirm Email
Work address*
Street Address Address Line 2 City State Postcode Country
Professional relationship of Participant Two to Participant One*
Mediation request or awareness*
Are there any special needs or culture needs that need to be considered? (e.g. interpreter etc)
Other relevant information

Your Name*
First Last
Your Email*
Enter Email Confirm Email
Company Name*
Your Contact Number*
Is this service or assessment being requested for yourself?*
Name of worker / client*
First Last
Client or Site contact number (including area code)*
Location of assessment or site IPAR required to attend*
What email address should IPAR invoices be sent to if services are provided?
What postal address should IPAR invoices be sent to if services are provided?
Invoice purchase order number

The following section requests information regarding the Client (injured worker or claimant)
Client Title*
Client Name*
First Last
Client Address*
Street Address Suburb State Postcode
Client Date of Birth*
DD slash MM slash YYYY
Client Gender*
Client Contact Phone Number
Client Alternative Phone Number
Client Email Address
Enter Email Confirm Email
Client Usual Occupation*
Interpreter required?
Language required*
Date of Injury or Condition*
DD slash MM slash YYYY
Nature of injury (please provide as much detail as possible)*
Claim Number (enter N/A if not applicable)*
Date of Notification
DD slash MM slash YYYY
Pre Injury Weekly Wage
Pre Injury Weekly Hours worked
Current weekly hours worked
Current RTW status*
If not working , please specify date client ceased work*
DD slash MM slash YYYY

The following section requests information about the referrer
Referrer Title
Referrer Name*
First Last
Referrer Role / Job Title
Referrer/ Insurer Company*
Referrer Address
Street Address Suburb State Postcode
Referrer Contact Phone Number*
Referrer Email
Should IPAR Invoices for services provided be sent directly to the above contact?*
Which email address should IPAR invoices be sent to?*
What address should IPAR invoices be sent to?*
Invoice purchase order number*

This section requests information about any current employer contacts to be involved in the assessment or RTW service.
Is the client currently attached to an employer who's contact details you would like to provide?*
Employer Company*
Employer Contact Name*
First Last
Employer Contact Position / Role
Employer Address*
Street Address Suburb State Postcode
Employer Contact Phone Number*
Employer Email
Enter Email Confirm Email
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

Are there any treating practitioner details you would like to provide?*
Treating Practitioner Name*
First Last
Treater Type*
Enter treater type*
Treating Practitioner Medical Centre/Hospital Name*
Treating Practitioner Address
Street Address Suburb State Postcode
Treating Practitioner Phone
Treating Practitioner Fax
Treating Practitioner Email
Enter Email Confirm Email
Are there additional treaters (medical practitioners) you would like to be involved in this referral?*
Additional Treating Practitioner Name*
First Last
Additional Treater Type*
Enter treater type*
Treating Practitioner Medical Centre/Hospital Name*
Additional Treating Practitioner Address
Street Address Suburb State Postcode
Additional Treating Practitioner Phone
Additional Treating Practitioner Fax
Additional Treating Practitioner Email
Enter Email Confirm Email

What type of Medicolegal Assessment do you require?*
What is the client's suburb and state?*
When is the Assessment required?*

Any additional details regarding your request?
Please provide further context around this assessment, such as the reason for referral*
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: 10 MB, Max. files: 4.
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.
CAPTCHA

Please complete the form below and a representative from IPAR will make contact with you

Step 1 of 11

Participant One

Participant Two

The following section requests information regarding the Client (injured worker or claimant)

The following section requests information about the referrer

This section requests information about any current employer contacts to be involved in the assessment or RTW service.

Service Provided

Employee details

Location of assessment

Employee availability

Preferred Equipment Supplier (If applicable)

News

Archive News