CMS QBE Referral Form Perth Date of Referral Case Manager Name * Case Manager Phone Number * Case Manager Team PER 1PER3PER 4BunburyAdvanced Claims Other Case Manager Team Case Managers Email Address * Type of Service Job SeekingLoss MitigationIndividual Services Claimant Name * Claimant Phone Number * Claimant Email * Claimant Address * Claim Number * Pre Injury Employer Pre-Injury Role Pre-Injury Earnings Date of Injury Medical Diagnosis * Pre Injury Hours 383736353433323130292827262524232221201918171615141312111098765432138+ Current Employment Status AttachedDetached Is the client legally represented? Not SureYesNo Is a Voc Rehab Provider working on the file? YesNo Voc Rehabilitation Provider Company Voc Rehabilitation Provider Consultant Work Status Code * 06 - Not Working No Current Capacity 08 - Not Working Has Current Capacity 09 - Not Working Not Entitled To Weekly Benefits 10 - Not working - Retired ( Weekly Payments Ceased Due To Retirement Limitation) 04 - Working - Different Employer - Current Work Capacity 03 - Working - Different Employer - Full Work Capacity 02 - Working Same Employer - Current Work Capacity 01 - Working - Same Employer - Current Work Capacity Weeks Paid * OO 1-117 117-260 Capacity in hours a day * 0 1 2 3 4 5 6 7 8 Capacity in Days 0 1 2 3 4 5 Notes Upload file Drop a file here or click to upload Choose File Maximum file size: 500MB File Upload Drop a file here or click to upload Choose File Maximum file size: 300MB File Upload Drop a file here or click to upload Choose File Maximum file size: 300MB Any other relevant info Submit 2019-08-09
