Referral Form

Refer Your Claimant for an Expert Medication Review Today

Ensure your claimants receive optimal care with our comprehensive medication reviews by completing the referral form below.

Referrer^*

Claim Number^*

Use a comma to separate multiple claim numbers.

Service^*

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First Name^*

Last Name^*

Date of Birth^*

Date of Injury^*

Accepted Conditions

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Referrer

Name^*

Phone^*

Email^*

Job Title^*

Company Name^*

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Reason For Referral

Questions for IMM Pharmacist

Documents

By submitting this form, you declare that the information provided is true and correct to the best of your knowledge.

Independent Med Management is committed to protecting the privacy of Injured Persons and Insurers and to handling personal information in a responsible manner in accordance with the Privacy Act 1988 (Cth), the Privacy Amendment (Enhancing Privacy Protection) Act 2012, the Australian Privacy Principles and relevant State and Territory privacy legislation (referred to as privacy legislation).