CMS Referral Form Suncorp/GIO Date of Referral Case Manager Phone Number * Case Manager Name * Case Managers Email Address * Claimant Name ID * Claimant Address * Claim Number * Claimant Contact Number * Claimant Email * PIAWE * Pre Injury Employer Pre-Injury Role Pre-Injury Earnings Date of Injury Current Employment Status 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 Medical Diagnosis * 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: 516MB File Upload Drop a file here or click to upload Choose File Maximum file size: 516MB Submit 2020-03-20
