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Reason For Referral *

Tell us why you are referring this claimant

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 - If you require IMM to contact treating doctors / pharmacies, please provide their details here.

Additional Details

Optional - Questions for our pharmacists and any additional context

Questions for IMM Pharmacist

Additional Context / Background

High-Risk Prescribing Check *

Would you like our pharmacists to review real time prescription monitoring as part of this service?

Yes

Real Time Prescription Monitoring (RTPM)

Our pharmacists have access to Australia's Real Time Prescription Monitoring system, providing instant visibility of a claimant's complete prescription history for high-risk medications including opioids, benzodiazepines, and other controlled medicines.

Benefits for referrers:

Identifies potential medication misuse, doctor shopping, or poly-pharmacy risks that may not be disclosed
Reveals the full picture of controlled substance prescriptions across all prescribers and pharmacies nationally
Supports evidence-based risk assessment and liability management
Enables early intervention before medication-related complications impact return-to-work outcomes

RTPM access is restricted to authorised prescribers and pharmacists under state and territory legislation.

Supporting Documents

Upload any supporting documents for this referral. All file types are accepted (for example PNG, JPEG, PDF, TXT, DOCX, CSV, or ZIP archives). Maximum 100 MB per file.

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).

Need assistance completing this form?

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Not sure what medications are being used? IMM can find out for you. Med-Info Retrieval & Risk Assessment is a stepped, pharmacist-led check that only goes as far as the risk justifies. It starts with a SafeScript / RTPM check across up to three states, and where high-risk medicines are identified, IMM retrieves the complete pharmacy dispense history and delivers a risk assessment report ready for the claim file.

No high-risk prescribing records found? The service stops there. You are only charged the referral processing fee, and IMM sends you confirmation that no high-risk drugs were identified, ready for the claim file.

3 days

Report finalised from referral

Stepped

Only pay for the steps needed

1 document

Certificate of Capacity only

Refer one claim or one hundred in a single submission. Upload a Certificate of Capacity for each person, claim details are read directly from each certificate.

1. Your details

Entered once, applies to every person in this referral.

Your name *

Organisation *

Email for report delivery *

Phone (optional)

2. Upload certificates

One certificate per person, up to 100 per referral. We read the claimant details and claim number from each certificate, so there is nothing to type.

Drop Certificates of Capacity or Fitness here, or click to browse

Select as many files as you like. PDF, JPG or PNG, max 50 MB each.

Uploading of

Which states do we check?

IMM checks the 3 most common state databases based on the address on the Certificate of Capacity, most commonly NSW, QLD and SA. If you would like additional states checked, we can add these as requested. Note it in the additional context below or contact us.

Additional context (optional, applies to the whole referral)

Want the full breakdown of each step? See Med-Info Retrieval & Risk Assessment on our Services page

Prefer email? Send the Certificates of Capacity straight through instead.

Email Us | Contact Page

Prefer a Fillable PDF?

Download our fillable PDF form to complete offline and email to admin@imedmanagement.com.au

Download PDF Form

Fillable PDF format

Can be saved and completed later

Email completed form to us

Established capability: 10,000+ medication assessments conducted across Workers' Compensation and CTP claims. Average report turnaround of 8 days, dependent on case complexity.