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Referral Form

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

Service required

Select the service you need for this case

Other Services

Legacy Service Notice

This is an IMM Legacy service available to existing contract holders of IMM. This service has been replaced with Pharmacy Review and Medication Management Services.

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

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.