Hearing Loss only – Referral to Medical Panel
(Instructions for completing form are on last page)
Hearing Loss Only - Referral To Medical Panel for an opinion pursuant to S104B(9) of the Accident Compensation Act 1985
1.REFERRER DETAILS
Referring Officer:Organisation:
Address:
Telephone No.:
Facsimile No.:
2.WORKER DETAILS
Given Name:Family Name:
Residential Address:
Date of Birth
Telephone No. Home:
Work:
Claim No.:
IB Application No.:
Date Claim Lodged:
Interpreter Required?
Language / Dialect
Legal Firm
Contact name of legal or other representative
Address:
Telephone No.:
3.EMPLOYER DETAILS
Name of Employer:Contact Person:
Telephone No.:
4.ACCEPTED INJURY
Hearing Loss
5.DATE OF INJURY
[Specify the one date of injury – S88(4), S104B(5A) & S104B(5B)]
6.ISSUES AND REASONS FOR REFERRAL
Provide a summary of the S104B process commencing from when the S98C claim was lodged, when the independent AMA4 was conducted, the advice of assessment, when the notification of entitlement was sent to worker and any other relevant information
(a.)[The worker’s name] lodged a S98C/E claim for [list injuries]
(b.)Liability was accepted/rejected for [list the accepted injuries]
(c.)Conciliation/Medical Panel or Court Outcome for the rejected injuries was that [insert outcome and include documents in referral]
(d.)[The worker’s name] was examined by [independent impairment assessor] who assessed the following [insert injuries]
7.NATURE OF THE DISPUTE - IMPAIRMENT BENEFITS – 98C & 98E / S104B REFERRALS
The matter has been referred to the Medical Panel as the worker has disputed the independent medical assessment made under S104B(4) & S104B(5).
Please note that S91(2) states that “in assessing a degree of impairment …regard must not be had to any psychiatric or psychological injury, impairment or symptoms arising as a consequence of, or secondary to, a physical injury.
8.MEDICAL QUESTIONS
a) What is the degree of permanent impairment resulting from industrial deafness assessed in accordance with S91 of the Act?
b) Does the worker have an accepted injury which has resulted in a total loss injury mentioned in the table in S98E(1)?
ENCLOSURE A
9.SCHEDULE OF ATTACHED REPORTS AND OTHER MATERIAL (List all documents and reports that are included in this Referral to the Medical Panel)
Worker: ______
Medical Panel Reference Number: ______
A. Agent/self-insurer to complete this section
Author of Report or document description / Date of Report / No. of pagesReferral to Medical Panel
B. This Section for Medical Panel use only
I refer to the Medical Panel convened in this matter of which I am the presiding member and acknowledge receipt of the medical and other material listed in this schedule and confirm that the Panel took this information into consideration in forming its opinion.
Presiding Member,
Medical Panel
Date
10.CERTIFICATION
I [full name]an employee of [name of organisation]
certify that: / (i)the worker has been advised of this referral to the Medical Panel for an opinion;
(ii)a copy of all relevant medical reports and information in the possession of my organisation is attached to the referral;
(iii)a complete copy of the referral (Sections 1 to 10 inclusive), including all attachments has been provided to the worker at the time of the referral; and
(iv)the worker has been advised that he/she can forward submissions and medical reports to the Medical Panel
Signature:
Date:
For agent/self-insurer:
Position
Instructions for completing section 104b (9) Medical Panel referral forms
These forms should be used for S98C and S98E referrals only and must be typed.
- 21.12.1 - Referral to Medical Panel
- 21.12.4 - Hearing Loss only - Referral to Medical Panel
Please refer to the following instructions when completing the forms.
Information / InstructionWorker’s address / It is imperative that agents provide the worker’s current address when making a referral to a Medical Panel. Agents should confirm the current address with the worker before completing the referral document.
Accepted injuries / Provide an accurate and full description of those injuries for which liability has been accepted as arising out of the one event or circumstance. Be precise as the worker may accept the psychiatric assessment but reject the physical assessment or vice versa.
For assessments of psychiatric impairment, occupational asthma or infectious occupational disease please state whether or not the updated guidelines apply in particular whether the initial impairment assessment was conducted on and after 28 July 2006
Date of Injury / Referrals should be limited to injuries arising from a single incident. If the worker has claimed for multiple incidents on the same claim form, a separate referral form for each incident should be submitted.
Issues and reason for referral / Record details of S104B (4) and (5) independent impairment assessment, the worker’s response to this assessment and any other information relevant to the Medical Panel referral. Also record details of any facts relevant to the S98C claim and whether they are agreed or disputed.
Schedule of reports / Enclosure A must always be on a separate page. All reports and correspondence relevant to the assessment should be recorded on this form and provided to the Medical Panel (see S65 (6A)). In addition include any:
Prior Medical Panel opinion and reason;
Conciliation Outcome Certificate;
The Notice of Entitlement and worker’s response; and
Where surveillance reports are provided, the corresponding videotape(s)/DVD/CD should also be included.
Certification / It is essential that agent’s/self-insurers ensure that all the information detailed in this section has been provided to the worker or his/her representative