CMS Referral Form Date of Referral Case Manager Phone Number * Case Manager Name * Case Managers Email Address * Claimant Name ID * Claimant Mobile Number * Claim Number * Claimant Email * Claimant Address * PIAWE * Pre Injury Employer * Pre-Injury Role * Pre-Injury Earnings * Date of Injury * Current Employment Status * Select Agency * IFNSWParramatta IFNSWNewcastle IFNSWParamatta Team Early Intervention 1 Early Intervention 2 Tail 1 Tail 2 Ambulance [if description] IFNSWNewcastle Team Early Intervention 1 Early Intervention 2 Tail 1 Tail 2 Ambulance 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 Agency * Aboriginal Housing OfficeAG'SAmbulance Service of NSWCentral Coast LHN ServicesCorrective ServicesDADHCDepartment of Family and Community ServicesDOCSE HealthFamily and Community Services Central CoastGovernment Workers Compensation AccountHealth Care Complaints CommissionHealth Support ServicesHunter/New England Area Health ServiceJenolan Caves Reserve TrustJustice HealthLegal Aid Commission of NSWLord Howe Island BoardMid North Coast LHN ServicesMinistry of TransportNorth Coast Area Health ServiceNorthern LHN ServicesNSW Health PathologyNSW Maritime AuthorityOffice of Environment and HeritageProtective CommissionerRail Workers FundRoyal RehabRoads and Maritime ServicesSydney Ports CorporationTaronga Conservation AuthorityOtherFACSNew Option Agency Weeks Paid * 0 1-117 117-260 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: 500MB File Upload Drop a file here or click to upload Choose File Maximum file size: 300MB Submit 2019-04-23
