Allied Health Treatment Request Form Instructions
This form contains 123 fields organized into 40 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Allied Health Discipline | ||
| Allied health discipline | Combobox |
Enter your allied health discipline (e.g., physiotherapy, occupational therapy, psychology) for this treatment request.
Please select
Physiotherapist
Psychologist
Chiropractor
Counsellor
Osteopath
Other (please specify)
Accredited Exercise Physiologist
|
| Other allied health discipline | Text |
If your discipline is not listed or does not fit the standard categories, specify the other allied health discipline here. Fill only if 'Allied health discipline' is 'Other'.
Depends on:
Allied health discipline
|
| Barriers to recovery identified | ||
| Barriers to recovery identified | Text |
Describe the barriers to recovery identified through your screening and assessment.
|
| Claim and Injury Details | ||
| Claim Number | Text |
Enter the insurer or scheme claim number for the injured person.
|
| Date of Injury/Crash | Date |
Enter the date the injury occurred or the crash happened.
|
| Collaboratively developed treatment plan (and explanation if not) | ||
| Yes | Checkbox |
Check this box if the treatment plan was collaboratively developed with the person with an injury.
|
| No | Checkbox |
Check this box if the treatment plan was not collaboratively developed with the person with an injury (and then provide an explanation).
|
| Reason treatment plan not developed collaboratively | Text |
Explain why the treatment plan was not collaboratively developed with the person with an injury. Fill only if 'No' is 'Yes'.
Depends on:
No
|
| Decision explanation | ||
| Decision explanation | Text |
Provide a detailed explanation of the insurer’s decision (e.g., approval of some services only, declined, or more information required). Fill only if 'Approval of some services only', 'Declined', 'More information required' is selected (any).
Depends on:
Approval of some services only, Declined, More information required
|
| Discharge planning (additional sessions and discharge date) | ||
| Additional sessions before discharge | Text |
Enter the number of additional treatment sessions you anticipate will be needed before the person is discharged.
|
| Anticipated discharge date | Date |
Provide the anticipated date the person is expected to be discharged from treatment.
|
| Reason discharge date changed | Text |
Explain why the anticipated discharge date has changed since the last treatment plan. Fill only if 'Anticipated discharge date' has changed since the last plan.
Depends on:
Anticipated discharge date
|
| Fifth Service Requested | ||
| Service Type (Fifth Service) | Text |
Enter the type of service being requested for the fifth service item (e.g., consultation type or aids/equipment).
|
| Number of Sessions/Hours (Fifth Service) | Number |
Enter the number of sessions requested, or the number of hours if the service is case conferencing, for the fifth service item.
|
| Frequency/Timeframe (Fifth Service) | Text |
Enter how often and over what timeframe the fifth service item will be provided (e.g., 1 consultation per week).
|
| Service Code (Fifth Service) | Text |
Enter the applicable service code for the fifth service item, if one applies.
|
| Cost per Session/Item (Fifth Service) | Number |
Enter the cost charged for each session or item for the fifth service item.
|
| Total Cost (Fifth Service) | Number |
Enter the total cost for the fifth service item.
|
| First Service Requested | ||
| Service Type | Text |
Enter the type of service requested (e.g., consultation type or other service such as aids/equipment).
|
| Number of Sessions/Hours | Text |
Enter the number of sessions requested, or the number of hours if the service is case conferencing.
|
| Frequency/Timeframe | Text |
Enter how often and/or over what timeframe the service will be provided (e.g., 1 consultation per week).
|
| Service Code | Text |
Enter the service code, if applicable for the requested service.
|
| Cost per Session/Item | Number |
Enter the cost for each session or item for the requested service.
|
| Total Cost | Number |
Enter the total cost for this requested service.
|
| First Standardised Outcome Measure (SOM) Row | ||
| SOM measure name (Row 1) | Text |
Enter the name of the standardised outcome measure used for the first row (e.g., Neck Disability Index, DASS).
|
| Initial SOM date (Row 1) | Date |
Enter the date the first (initial) standardised outcome measure was completed for this measure.
|
| Initial SOM score (Row 1) | Text |
Enter the score(s) from the first (initial) completion of this standardised outcome measure.
|
| Previous SOM date (Row 1) | Date |
Enter the date the SOM was completed for submission of the previous AHTR for this measure.
|
| Previous SOM score (Row 1) | Text |
Enter the score(s) recorded for this measure at the previous AHTR submission.
|
| Current SOM date (Row 1) | Date |
Enter the date the latest (current) SOM was completed for this measure.
|
| Current SOM score (Row 1) | Text |
Enter the score(s) from the latest (current) completion of this standardised outcome measure.
|
| Fourth Service Requested | ||
| Service Type | Text |
Enter the type of service requested (including consultation type or other services such as aids/equipment).
|
| Number of Sessions/Hours | Number |
Enter the number of sessions requested, or the number of hours if this is for case conferencing.
|
| Frequency / Timeframe | Text |
Enter how often and over what timeframe the service will occur (e.g., 1 consultation per week).
|
| Service Code | Text |
Enter the applicable service code for the requested service, if available.
|
| Cost per Session/Item | Number |
Enter the cost for each session or item requested.
|
| Total Cost | Number |
Enter the total cost for this requested service line item.
|
| Goals achieved since last treatment plan | ||
| Check Box 15 | CheckBox | |
| No | Checkbox |
Check this box if the person with an injury has not achieved the goals from the last treatment plan.
|
| Yes | Checkbox |
Check this box if the person with an injury has achieved the goals from the last treatment plan.
|
| N/A | Checkbox |
Check this box if achieving the goals from the last treatment plan is not applicable.
|
| Injured Person Identification | ||
| Injured person full name | Text |
Enter the full legal name of the person who was injured.
|
| Date of birth | Date |
Enter the injured person's date of birth.
|
| Insurer contact details | ||
| Insurer contact name | Text |
Enter the name of the insurer representative who can be contacted about this decision.
|
| Insurer contact phone number | Text |
Enter the phone number for the insurer contact person.
|
| Insurer contact email | Text |
Enter the email address for the insurer contact person.
|
| Insurer decision date | ||
| Insurer decision date | Date |
Enter the date the insurer signed and made the decision on this request.
|
| Insurer decision selection | ||
| Approved | Checkbox |
Check this box if the insurer approves all requested services.
|
| Approval of some services only | Checkbox |
Check this box if the insurer approves only some of the requested services (not all).
|
| Declined | Checkbox |
Check this box if the insurer declines the requested services.
|
| More information required | Checkbox |
Check this box if the insurer needs additional information or documentation before making a decision.
|
| Interpretation of score(s) | ||
| Score interpretation | Text |
Provide your interpretation of the reported standardised outcome measure score(s), including what the results indicate about the person’s current status and any clinically meaningful change over time.
|
| Overall Total Cost | ||
| Overall total cost | Number |
Enter the total combined cost for all services/items listed in this section.
|
| Person's goals (work and activity/participation) | ||
| Work goal (SMART) – To … by … | Text |
Enter the person’s SMART work goal (or activity goal if not working at the time of injury), stating what they aim to achieve and the target completion date.
|
| Activity/participation goal (SMART) – To … by … | Text |
Enter the person’s SMART activity or participation goal, stating what they aim to achieve and the target completion date.
|
| Position Description/Work Duties Copy Available | ||
| Check Box 5 | CheckBox | |
| Yes — Copy available | Checkbox |
Check this box if you have a copy of the position description/work duties (for workers compensation and, where relevant, CTP).
|
| Practice Address and Contact Details | ||
| Practice name | Text |
Enter the name of the practice/clinic.
|
| Suburb | Text |
Enter the suburb where the practice is located.
|
| State | Text |
Enter the state or territory for the practice address.
|
| Postcode | Text |
Enter the postcode for the practice address.
|
| Phone number | Text |
Enter the practice phone number.
|
| Fax | Text |
Enter the practice fax number, if applicable.
|
| Practice email | Text |
Enter the practice email address.
|
| Best time/day to contact | Text |
Enter the preferred day(s) and time(s) to contact the practice.
|
| Pre-existing Conditions Relevant to Compensable Injury | ||
| Pre-existing Conditions Relevant to Injury | Text |
Enter details of any pre-existing medical conditions that are directly relevant to the compensable injury.
|
| Pre-injury Work Details | ||
| Pre-injury occupation | Text |
Enter the worker’s job title or occupation held immediately before the injury.
|
| Average pre-injury work hours per week | Number |
Enter the average number of hours the worker worked per week before the injury.
|
| Rationale for requested services | ||
| Rationale for Requested Services | Text |
Provide a detailed explanation of why the requested treatment services are needed, including clinical justification and how they will help achieve the person’s recovery goals.
|
| Referrer Details | ||
| Referred by | Text |
Enter the name of the person or organisation that referred the patient for allied health treatment.
|
| Referrer phone number | Text |
Enter the phone number of the referrer.
|
| Request Identification | ||
| Request number | Text |
Enter the sequential request form number for this person’s treatment request (e.g., 1 for the first request submitted).
|
| Date of request | Date |
Enter the date this allied health treatment request is being made.
|
| Requested assistance (insurer contact / case conference / independent consultant review) | ||
| Direct contact from the insurer — Yes | Checkbox |
Check this box if you want the insurer to contact you directly regarding assistance or next steps.
|
| Case conference — Yes | Checkbox |
Check this box if you want a case conference to be arranged (with the relevant participants listed in the “who with” space).
|
| Case conference participants | Text |
Enter the name(s) of the person or people you would like to include in the case conference. Fill only if 'Case conference — Yes' is 'Yes'.
Depends on:
Case conference — Yes
|
| Collaborative case review with an independent consultant — Yes | Checkbox |
Check this box if you want an independent consultant to conduct a collaborative case review.
|
| Risk Screening Details | ||
| Check Box 29 | CheckBox | |
| Yes (risk screening tool applied) | Checkbox |
Check this box if you have applied a risk screening tool as part of your clinical assessment.
|
| Risk screening tool name | Text |
Enter the name of the risk screening tool applied in the assessment (e.g., OMPSQ-SF, Keele STarT Back, Whip-Predict, K10). Fill only if 'Yes (risk screening tool applied)' is 'Yes'.
Depends on:
Yes (risk screening tool applied)
|
| Date administered | Date |
Enter the date the risk screening tool was administered. Fill only if 'Yes (risk screening tool applied)' is 'Yes'.
Depends on:
Yes (risk screening tool applied)
|
| Risk screening score/comment | Text |
Provide the risk screening score and/or any relevant comments or interpretation of the result. Fill only if 'Yes (risk screening tool applied)' is 'Yes'.
Depends on:
Yes (risk screening tool applied)
|
| Second Service Requested | ||
| Second service type | Text |
Enter the type of the second service being requested (e.g., consultation type or other service such as aids/equipment).
|
| Second service number of sessions/hours | Number |
Enter the number of sessions requested for the second service, or the total hours if the service is case conferencing.
|
| Second service frequency/timeframe | Text |
Describe how often and over what timeframe the second service will be provided (e.g., one consultation per week).
|
| Second service code | Text |
Enter the applicable service code for the second requested service, if one applies.
|
| Second service cost per session/item | Number |
Enter the cost for each session or item for the second requested service.
|
| Second service total cost | Number |
Enter the total cost for the second requested service.
|
| Second Standardised Outcome Measure (SOM) Row | ||
| SOM measure name (Row 2) | Text |
Enter the name of the second standardised outcome measure used (e.g., Neck Disability Index, DASS).
|
| Initial SOM date (Row 2) | Date |
Enter the date the first (initial) score for this outcome measure was completed.
|
| Initial SOM score (Row 2) | Text |
Enter the initial score results for this outcome measure.
|
| Previous SOM date (Row 2) | Date |
Enter the date the previous score for this outcome measure was completed.
|
| Previous SOM score (Row 2) | Text |
Enter the previous score results for this outcome measure.
|
| Current SOM date (Row 2) | Date |
Enter the date the latest (current) score for this outcome measure was completed.
|
| Current SOM score (Row 2) | Text |
Enter the current score results for this outcome measure.
|
| Section 2: Your clinical assessment | ||
| Compensable injury or illness | Text |
Enter a brief description of the compensable injury or illness being treated.
|
| Current clinical signs and symptoms | Text |
Describe the patient’s current clinical signs and symptoms relevant to the injury or illness.
|
| Self-management between sessions | ||
| Self-management activities between sessions | Text |
Describe the self-management techniques, strategies, and/or exercises the person with an injury is completing between treatment sessions.
|
| Service History | ||
| Date Services First Commenced | Date |
Enter the date the allied health services for this injury first commenced.
|
| Total Consultations to Date | Text |
Enter the total number of consultations provided to the worker to date for this request.
|
| SIRA Approval Number (Workers Compensation Only) | ||
| SIRA Approval Number | Text |
Enter the SIRA approval number applicable to this request (workers compensation only).
|
| Strategies to address barriers to recovery | ||
| Recovery Barrier Strategies | Text |
Describe the strategies and actions planned to address barriers to recovery, including steps by the injured person, agreed treatment-team strategies, and any referrals to other services.
|
| Third Service Requested | ||
| Service Type (Third Service) | Text |
Enter the type of service being requested for the third service line (e.g., consultation type or other service such as aids/equipment).
|
| Number of Sessions/Hours (Third Service) | Text |
Enter the number of sessions requested, or the number of hours if this service is case conferencing, for the third service line.
|
| Frequency/Timeframe (Third Service) | Text |
Enter how often and over what timeframe the third service will occur (e.g., 1 consultation per week).
|
| Service Code (Third Service) | Text |
Enter the applicable service code for the third service, if one applies.
|
| Cost per Session/Item (Third Service) | Number |
Enter the cost for each session or item for the third service.
|
| Total Cost (Third Service) | Number |
Enter the total cost for the third service.
|
| Third Standardised Outcome Measure (SOM) Row | ||
| SOM 3 Measure | Text |
Enter the name of the third standardised outcome measure used (e.g., Neck Disability Index, DASS).
|
| SOM 3 Initial Date | Date |
Enter the date the first assessment for this outcome measure was completed.
|
| SOM 3 Initial Score | Text |
Enter the score(s) recorded for the first assessment of this outcome measure.
|
| SOM 3 Previous Date | Date |
Enter the date the previous assessment for this outcome measure was completed (as reported in the previous AHTR).
|
| SOM 3 Previous Score | Text |
Enter the score(s) recorded for the previous assessment of this outcome measure.
|
| SOM 3 Current Date | Date |
Enter the date the latest (current) assessment for this outcome measure was completed.
|
| SOM 3 Current Score | Text |
Enter the score(s) recorded for the latest (current) assessment of this outcome measure.
|
| Treating Practitioner Identification | ||
| Treating practitioner name | Text |
Enter the full name of the treating practitioner.
|
| AHPRA registration or membership number | Text |
Enter the treating practitioner's AHPRA registration number or professional membership number.
|
| Treating practitioner email | Text |
Enter the email address of the treating practitioner.
|
| Usual Activities Capacity (Second Row) | ||
| Usual activities (pre-injury capacity) | Text |
Describe the person’s usual activities before the injury, such as daily living activities, driving, transport, and leisure.
|
| Usual activities (current capacity) | Text |
Describe what the person can currently do regarding usual activities, such as daily living activities, driving, transport, and leisure.
|
| Work Capacity (First Row) | ||
| Pre-injury Work Capacity | Text |
Describe the person’s work before the injury for this claim, including occupation, tasks performed, and typical days/hours worked.
|
| Current Work Capacity | Text |
Describe what the person can do now for work, including current abilities, duties they can perform, and any limitations affecting days/hours worked.
|
| Your intervention | ||
| Your intervention details | Text |
Describe the intervention you will provide, including key treatment approaches and any strategies or exercises the person will complete between sessions.
|