Workers Compensation Case Manager Form
Client Information
First Name
*
Last Name
*
Phone Number
Email Address
*
Case Manager Information
First and Last Name
*
Contact Number
*
Contact Email
Insurance Company Name
Claim Number
Confirmation of Work Cover Approval Letter
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Approval of how many sessions?
*
When do you require the psychologist to submit AHTR/PMP progress reports? (after how many sessions)
*
The client has given consent to the exchange of information between case manager and treating psychologist.
Yes
No
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