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Forms

Here is a list of ReturnToWorkSA forms, sorted in alphabetical order.

For further information or advice, please contact us on 13 18 55 or email info@rtwsa.com.

If you experience any issues downloading forms, please contact us on 13 18 55.

Authority to obtain information form (Amharic)
Authority to obtain information form translated to Amharic

Authority to obtain information form (Arabic)
Authority to obtain information form translated to Arabic

Authority to obtain information form (Chin Hakka)
Authority to obtain information form translated to Chin Hakka

Authority to obtain information form (Chinese)
Authority to obtain information form translated to Chinese.

Authority to obtain information form (Dari)
Authority to obtain information form translated in Dari

Authority to obtain information form (Dinka)
Authority to obtain information form translated in Dinka

Authority to obtain information form (English)
When completed, the authority to obtain information form gives the Return to work service provider permission to obtain information relevant to a workers return to work activity.

Authority to obtain information form (Hindi)
Authority to obtain information form translated to Hindi

Authority to obtain information form (Khmer)
Authority to obtain information form translated to Khmer.

Authority to obtain information form (Kurdish)
Authority to obtain information form translated to Kurdish.

Authority to obtain information form (Nepali)
Authority to obtain information form translated to Nepali

Authority to obtain information form (Persian)
Authority to obtain information form translated to Persian

Authority to obtain information form (Spanish)
Authority to obtain information form translated to Spanish.

Authority to obtain information form (Swahili)
Authority to obtain information form translated to Swahili.

Authority to obtain information form (Vietnamese)
Authority to obtain information form translated in Vietnamese.

Chiropractic management plan
The Chiropractic management plan should be completed where more than 10 treatment sessions will be delivered within a practice, or as requested by the case manager.

Claim form
Call your claims agent or ReturnToWorkSA on 13 18 55 as this form may not be required.

Direct debit request form
Direct debit is a low cost, convenient way to ensure that your monthly instalments are paid on time.

Electronic funds transfer (EFT) form
Electronic funds transfer (EFT) form for medical, allied health and return to work service providers.

Employer registration additional location form
Complete this form if you need to update your workplace location details.

Employer registration amendment form
This form allows registered employers to amend their business information and existing location information with ReturnToWorkSA. These changes can also be made via our online services portal.

Employer registration form
Use this form to register as an employer to receive insurance cover with ReturnToWorkSA. Employers must register within 14 days of employing a worker.

Freedom of information (FOI) application for access form
This form should be completed for Freedom of information requests.

Freedom of information (FOI) internal review application form
Please complete this form if you wish to request a review of a Freedom of information determination.

Insurance premium calculator
This premium calculator will provide you with an estimate for your insurance premium.

Medical expenses application for pre-approval form.pdf
Complete this form if you need to apply for pre-approval for medical expenses.

My treatment - what do I want to achieve form
This form is a valuable tool to help allied health practitioners treat patients' needs.

Nurse practitioner work capacity certificate
Nurse practitioners can use the Nurse Practitioner Work Capacity Certificate when a person with a new work injury presents to a hospital emergency department.

Occupational therapy management plan
The Occupational therapy management plan should be completed where more than 10 sessions will be delivered within a practice, or as requested by the case manager.

Osteopathy management plan
The Osteopathy management plan should be completed where more than 10 treatment sessions will be delivered within a practice, or as requested by the case manager.

Physiotherapy management plan
The Physiotherapy management plan should be completed where more than 10 treatment sessions will be delivered within a practice, or as requested by the case manager.

Physiotherapy restricted consultation application
This application form needs to be completed if a physiotherapist is looking to undertake a restricted consultation.

Psychology management plan
The Psychology management plan should be completed where more than 10 treatment sessions will be delivered within a practice, or as requested by the case manager.

Recovery return to work plan
A recovery/return to work plan is to be developed if you are likely to be away from work for more than four weeks.

Return to work coordinator appointment and change of details form
Complete this form to appoint or change the details of your Return to Work Coordinator. All businesses in South Australia who employ 30 or more workers are required to appoint and retain a trained return to work coordinator.

RISE Job vacancy information and approval form
Re-employment incentive scheme for employers (RISE) - Job vacancy information and approval form.

RISE Wage reimbursement request form
Re-employment incentive scheme for employers (RISE) - Wage reimbursement request form

Section 15(2) Request to investigate employer compliance form
Please complete this form if you want ReturnToWorkSA to investigate a circumstance where you believe your employer has not complied with the retention, employment or re-employment requirements of the Act.

Section 157 application for review (Employer) form
Registered employers should complete this form if they want a review of a decision about their insurance premium.

Section 180 internal review application form
Please complete this form if you want to request a review of a decision regarding access to information under Section 180.

Section 185 request for exchange of information form
This form should be completed by claims agents or self insured employers when they need to exchange information about a workers' claim(s).

Secure online services user registration form
Self-insured employers and service providers should complete this form if they require access to our secure online services to view/submit electronic work capacity certificates, submit claims data or perform electronic invoicing.

Self-insured claim investigation application form.pdf
To apply for an authority under Section 183 for Self-Insured employers, please use this form.

Self-insured employer self assessment
A report provided by self-insured employers to ReturnToWorkSA during a registration period.

Self-insured notice of lump sum determination return form
This form is used to notify us of lump sum payments.

Service provider registration form
Return to work service provider registration form.

Speech pathology management plan
The Speech pathology management plan should be completed where more than 10 treatment sessions will be delivered within a practice, or as requested by the case manager.

User guide for installation of eWCC for Medical Director
This is a user guide for the installation of the eWCC widget into Medical Director software.

Whole person impairment physical assessment report template
Compulsory whole person impairment physical assessment report template for accredited ReturnToWorkSA impairment assessors.

Whole person impairment psychiatric assessment report template
Compulsory whole person impairment psychiatric assessment report template for accredited ReturnToWorkSA impairment assessors.

Work capacity certificate
The work capacity certificate is an important tool for documenting a medical assessment of a patient's injury and their capacity to return to work.