Practitioner/Clinic Application * Required fields Are you currently an existing InjuryNET clinic? Yes No Pre-Qualification Questions InjuryNET’s services are based on open communication and commitment to the management and provision of high quality health services that achieve our clients’ objectives. Please indicate your ability/willingness to provide the following: Appointment Availability Are you able to provide same day/next day appointments for injured workers? Yes No Unsure Are you able to provide appointments with 3 business days for Pre-Employment Medical Services? Yes No Unsure Communication Are you willing to communicate with InjuryNET and our clients regarding injured workers and their treatment? Yes No Unsure Are you willing to actively communicate with InjuryNET regarding changes to clinic or practitioner details? Yes No Unsure Certification Are you willing to certify injured workers based on their capacity to work, and certify unfit only when medically appropriate? Yes No Unsure Medical Assessment Forms Are you able to email or fax fully completed Pre-Employment Medical Forms back to InjuryNET within two hours of the appointment occurring? Yes No Unsure Clinic Details Clinic Type Medical Clinic Physiotherapy Clinic Psychology Clinic Clinic Name:* Clinic ABN:* Clinic Address:* Suburb:* State:* Please select... ACT NSW NT QLD SA TAS VIC WA Postcode:* Postal Address: (if different from above) Suburb: State: Please select... ACT NSW NT QLD SA TAS VIC WA Postcode: Clinic Email:* Clinic Phone Number:* (including area code) Clinic Fax Number: (including area code) Is your practice accredited against the RACGP standards? Yes No Unsure Your Details Are you a: Doctor Practice Manager Physiotherapist Key Contact The Key Contact: Must be a Senior Physiotherapist or Clinic Owner as this person will be the main point of contact for InjuryNET. Determines which Physiotherapists are suitable and interested in participating in InjuryNET programs and coordinates InjuryNET training for all participating physiotherapists within the clinic (participating practitioners must be registered with AHPRA). Will be responsible for the services provided by the participating Physiotherapists at the clinic. Will be responsible for keeping participating Physiotherapist up to date with information provided by InjuryNET, e.g. client information, policies, procedures and fee schedules Title:* Please select... Dr Miss Mr Mrs Ms First Name:* Surname:* Email:* AHPRA Reg No:* Languages spoken: (other than English) Send me updates via email about InjuryNET services
