Medical authority to obtain/release information

To support your recovery and assist with your safe and timely return to work, we may require medical information that helps us understand the nature of your work-related injury or illness, your current capacity, and your prognosis.

This authority allows your treating health care providers to share relevant information with your employer’s appointed Return to Work Coordinator or representative. All information will be handled in accordance with the Return to Work Act and applicable privacy laws.

If you have any concerns about confidentiality, please speak with your Return to Work Coordinator.

Worker Authority

I, (insert worker’s full name), hereby authorise my treating doctor(s) and/or other relevant medical professionals.

You can choose to specify your treating providers, but this is optional. If you would like to specify your treating providers, please list their names below:

Click or tap here to enter text.

to release information relevant to my work-related injury or illness to my employer’s appointed Return to Work Coordinator or representative,

(insert name of coordinator or representative such as Manager/Leader/other relevant persons)

Click or tap here to enter text.

This information may include, but is not limited to:

Diagnosis and nature of the injury or illness

Your treatment and progress

Functional capacity and work restrictions

Prognosis for recovery and return to work.

I understand that this information will be used solely for the purpose of managing my recovery and facilitating
my return to work.

Worker’s full name:	Click or tap here to enter text.

Worker’s signature:	Click or tap here to enter text.

Date:	Click or tap to enter a date.

**IMPORTANT: This authority does not provide consent for your employer/Return to Work Coordinator to be present whilst you are being examined or treated by your health practitioner or where you are undergoing diagnostic examinations or tests required for treatment purposes.

***Delete This Box*** Provide a copy of this authority when communicating with the worker’s treating provider(s) Identify the way the doctor/physiotherapist/other would like to communicate with you and adapt your approach Make sure the provider is aware of your role to assist and support their patient to recover and return to work Refer to Section 186 of the Return to Work Act 2014 for more detail.