Third Party Insurer Claim

Centered H3 Example

Full Name (including Title)

Phone - Mobile Number

Patient Email address:

Patient work status:

Written approval Obtained? Yes/NO

Would you like to attend the appointment by zoom?

Yes No

Would you like to attend the appointment in person with the patient?

Yes No

History and Treatment to date:

Referral Information

If this referral is for an ACC patient:

Please ensure there is an ACC claim with a Read Code that matches the body part being referred for assessment.
Please provide copies of any relevant clinical documentation for review before the appointment (specialist reports etc).
The "Private" fee will apply if there are no current ACC claim details provided.
Please forward written confirmation of funding for the appointment from the Insurer/Third party funder (if applicable).

THANK YOU FOR YOUR REFERRAL.

A FULL REPORT WILL BE PROVIDED WITHIN 7 DAYS OF THE CONSULTATION.

Referral Information