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Referral Form

Complete the form below to request a pharmacy review or medication management service

Submitting Your Referral

Please wait while we securely process your submission and prepare your confirmation...

Service required

Select the service you need for this case

Other Services

Claimant Details

Information about the injured person

Claim Number^*

Use a comma to separate multiple claim numbers.

First Name^*

Last Name^*

Date of Birth^*

Date of Injury^*

Accepted Conditions

Declined Conditions

Referrer Details

Your contact information

Referrer

Name^*

Phone^*

Email^*

Job Title^*

Company Name^*

Generic Company Email^*

Add Team Lead / IMA / IMS details

Treatment Providers

Optional - Add treating doctors and pharmacies

Request High-Risk Prescribing Check

Yes

Real-time prescription monitoring to identify high-risk use, duplication, and potential misuse

Additional Details

Optional - Additional information

Reason For Referral

Questions for IMM Pharmacist

Supporting Documents

Upload any supporting documents for this referral

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).

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Established capability: 12,000+ medication assessments conducted across Workers' Compensation and CTP claims. Average report turnaround of approximately 10 business days, dependent on case complexity.