Allied Health Treatment Request Form Completed Form Examples and Samples

Progress Notes: 15 February 2026. Patient: Marcus V. Thorne (DOB: 12/04/1982). Current claim number is WC-99284-B. Marcus, a warehouse manager who typically handles 45 hours a week, sustained a lumbar strain on 10 January 2026. We are submitting this as our 2nd request for treatment. Services commenced on 20 January 2026, and we have completed 6 consultations to date. Referring physician Dr. Sarah Jenkins (02-555-0199) confirms the injury. During my assessment, I applied the Keele STarT Back tool on 10 February 2026, which yielded a score of 7, indicating high risk. Currently, Marcus reports significant lower back pain (VAS 7/10) with limited range of motion. I have reviewed his job description provided by his employer. Barriers to recovery include anxiety regarding return-to-work deadlines and persistent pain. We’ve set a work goal: to lift 5kg without guarding by 15 April 2026. For activity, he aims to resume driving for 30 minutes by 30 March 2026. For our intervention, I plan to utilize manual therapy and core stabilization exercises, focusing on home-based self-management. I am requesting 8 follow-up physiotherapy sessions (Code: PHYS-99) at $120 each, totaling $960. My registration number is PHY-88201. Please reach out to me at my clinic, 'Sydney Central Physio', located at 12 George St, Sydney, NSW, 2000. Phone: 02-9988-7766, Fax: 02-9988-7777, Email: [email protected]. I prefer contact on Tuesday mornings. SIRA approval number: SIRA-5542.