Request for surgery approval More information

This form is only to be used for claims where WorkCover Queensland is the insurer. Please clearly PRINT or type your answers in the allocated spaces below.

Apply for surgery approvalOnline at www.workcoverqld.com.auBy email to your customer advisor at

givenname.familyname@workcoverqld.com.au

By fax to 1300 651 387

For more information, visit our website at www.workcoverqld.com.au or call us on 1300 362 128.

Worker detailsSurname or family name of worker

     

Given names of worker     

Claim number     

Date of birth   /  /    

Request for surgeryAnticipated item number/s and Surgery to be performed

           

           

           

           

Proposed admission date   /  /    

Proposed Hospital for admittance     

Number of nights     

Anticipated Implants/Prosthetic to be used     

     

     

     

     

Time to post-operative consultation      weeks

Medical practitioner detailsSignature      

Full name      Practice      Telephone       Fax      

Email      

Date   /  /    

If the following three questions are answered, please charge to item code 100808.

What is the current work-related diagnosis?     

Is the surgery proposed to treat the work-related injury or a pre-existing condition – with explanation?

     

Please provide an outline of the expected timeframes for return to work and recovery, and the type, frequency and duration of any rehabilitation.

     

Please noteSurgical fees must be based on the Medical Items—Schedule of Fees.

No fee is payable for submitting this request, unless questions 11 – 13 are answered in full.

For more information about how we approve surgery requests, visit our website at www.workcoverqld.com.au.

Full name      

Date  /  /     I agree

Page 1 of 1FM302

1

2

3

5

6

8

10

4

9

7

11

12

13