Documents and forms

This section has links to brochures and commonly used forms for TAC health and service providers.

Most requested provider forms and brochures

Forms

Acupuncture treatment questionnaire (Provider use only)

For acupuncture practitioners – use this form, when requested by us, to provide us with an overview of your patient's health, their work/functional status, treatment plan, progress, limitations and your advice for the self-management of their condition.

For help completing this form, see the separate notes document.

Audiology - Hearing assessment and device request form

This form is to be completed when requesting hearing devices for our clients. You need to include clinical notes and the hearing assessment information with the form.

Australian Holiday Support Request form (for Provider use only)

For occupational therapists – complete this form to request attendant care for holiday support and identify client support needs. This form can be completed by an Occupational Therapist in conjunction with a Community Access Planner.

Authority to release information form - client representatives

For client representatives – complete this form to provide us with permission to obtain information and documents from your client’s medical practitioners, employer, government agencies and other relevant parties regarding their claim, their health and their employment details.

Burial/Cremation and Dependency Benefits claim form

For families and representatives – complete this form to make a claim for funeral, burial and cremation expenses, and/or dependency benefits, for a person who has died as a result of a transport accident.

The form introduction explains what information and official documents need to be provided.

Certificate of Capacity form

The Certificate of Capacity form is for authorised providers to provide information about their TAC patient's transport accident conditions and to assess and certify their capacity for work as a result of these injuries.

IMPORTANT NOTICE:
It is an offence under the legislation to provide false or misleading information. A person who provides a false or misleading certificate of capacity could be liable to prosecution.

Please provide feedback about the Certificate of Capacity to medicalcertificatefeedback@tac.vic.gov.au

Certificate of Capacity user guides

For medical practitioners –these step-by-step user guides will help you to access and complete a Certificate of Capacity using your clinic's software. User guides for 'Best Practice' and 'Medical Director' software packages are available.

Chiropractic treatment questionnaire

For chiropractic practitioners – use this form, when requested by us, to provide us with an overview of your patient's current status, including ongoing improvements and any barriers to recovery that may exist.

For help completing this form, see the separate notes document.

Client Progress Report (for Outreach or Case Management services)

Outreach and Case Management service providers are required to complete and submit Client Progress Reports using this template every three months to the client’s TAC Coordinator.

The purpose of the report is to provide the TAC with information regarding client progress, it also provides the basis for follow up discussions with the TAC either in person or over the phone.

Community Access Plan: Initial plan and request for funding form (for Provider use only)

For Medical Practitioners and Allied Health providers: When clients with multiple physical, sensory and cognitive disabilities need support to access and participate in recreational and leisure activities, a community access plan can assist.

Community Access Plan: Progress and/or outcome report form (for Provider use only)

Our attendant care providers support clients to achieve their independence goals in daily living activities, therapy support, personal and domestic skills retraining and community access skills.

Community discharge assessment form

For case managers – use this form to discuss and report on your client's specific circumstances, interests and objectives, to prepare an effective plan for their discharge from hospital into the community.

For help completing this form, see the separate notes document.

Community Group Program: Hours request form (for Provider use only)

For community group providers – complete and return this form to provide an overview of your client’s activities, goals and the expected outcomes of their participation in your community group programs.

Continence equipment prescription and order form: Community form (for provider use only)

For community continence nurses – use this form to request continence equipment for your patient. You will need to provide a summary of the continence assessment, along with your recommendations.

The form should also be completed when a major review of the continence equipment requirements is conducted (usually every two years) or when there has been a change to the current continence regime.

For help completing this form, see the separate notes document.

Continence equipment prescription and order form: Hospital discharge

For hospital continence nurses – use this form to request continence and related equipment for patients transitioning to the community. You will need to provide a summary of the continence issues and routine, along with suggested goals re their bowel and/or bladder movement.

The form should also be completed when a major review of the continence equipment requirements is conducted (usually every two years) or when there has been a change to the current continence regime.

For help completing this form, see the separate notes document.

Dental: dental report form

For dental providers – use this form, when requested by us, to report damage caused to a patient's teeth and mouth as a result of their transport accident, and to propose a treatment plan.

Dental: maxillo facial report form

For dental or maxillofacial providers – use this form, when requested by us, to report damage caused to a patient's jaw or face as a result of their transport accident, and to outline the treatment given.

Education support services: Application for aide, teacher or tutoring request form

For schools and educational facilities – complete this form to request educational support services, such as an aide, teacher or tutor, to assist our clients who have been injured in a transport accident and are students.

For help completing this form, see the separate notes document.

Education support: individual education plan

For schools and educational facilities – if you are requesting educational support services, please complete these record sheets to outline the learning goals that the student is expected to achieve once support is in place.

EFT/Direct Deposit Authority form (only for use by existing TAC providers)

For existing health and service providers – use these forms to register your banking details with us, so that your payments can be transferred direct to your bank account, or to change the account details you had registered previously.

Epworth Hospital Transitional Living Centre - Request for admission extension form

For Epworth Hospital staff – use this form to request an extended stay at the Transitional Living Centre for a TAC client.

This form should be read in conjunction with Rehab Online documentation.

Epworth Hospital Transitional Living Centre - Request for admission form

For Epworth Hospital staff – use this form to request admission for a TAC client to the Transitional Living Centre.

This form should be read in conjunction with Rehab Online documentation.

Equipment prescription form (for Provider use only)

This form must be completed for the TAC to consider requests for a variety of equipment, including wheelchairs, press cushions, powered conversions kits, hoists, scooters, bikes and recumbent trikes, beds, mattresses, standing frames, tilt tables, treatment couches, large exercise equipment, lounge chairs and custom toilet/shower/commode chairs. The separate 'notes' document in this section provides additional instructions and clarification to help complete the form.

If you are requesting high cost/complex items that require customisation, you will also be required to attach a standardised quote from the equipment supplier to the Equipment Prescription Form.  The equipment supplier can either use the Equipment Prescription Form Quote Template or they can use their own business format as long as it supplies the same information as our template.  A seperate 'notes' document is also available which provides detailed instructions to assist the supplier complete the quote template.

Exercise Physiology Review form (for Provider use only)

For exercise physiologists – complete and submit this form if we request an EPR.

An Exercise Physiology Review form (EPR) includes information on the patient’s clinical diagnoses, proposed treatment plan, self-management strategies and outcome measures.

Framework Occupational Therapy Application form

This form is used by Occupational Therapists to register with the TAC (and/or WorkSafe) as a provider of Framework OT services.

Functional Independence Assessment: Accommodation and Allied Health Service Recommended form (for Provider use only)

For occupational therapists – in consultation with other treating therapists and the Early Support Coordinator, complete this form in preparation for a client’s discharge from hospital.  To ensure the client makes a smooth transition from hospital to the community, the assessment considers the most suitable accommodation, as well as the allied health and therapy services they will need.

For help completing this form, see the separate notes document.

Functional Independence Assessment: Attendant Care and Allied Health Service Recommendations form (for Provider use only)

For occupational therapists – in consultation with other treating therapists and the Early Support Coordinator, complete this form in preparation for a client’s discharge from hospital.  To ensure the client makes a smooth transition from hospital to the community, the assessment considers the attendant care and other allied health and therapy services they will need.

For help completing this form, see the separate notes document.

Functional Independence Review form (for Provider use only)

For occupational therapists – when requested by us, complete these forms to review the functional capacity of a client, such as the physical, cognitive and emotional functioning, as well as communication skills, and to evaluate their progress toward increased independence.

For help completing this form, see the separate notes document.

Functional Independence Review: Supported Accommodation form (for Provider use only)

For occupational therapists – when requested by us, complete this form to review the functional capacity, such as the physical, cognitive and emotional functioning, as well as communication skills, of a client living in supported accommodation, and to evaluate their progress toward increased independence.

For help completing this form, see the separate notes document.

Gym/Swim program: evaluation form (for Provider use only)

For allied health professionals – use this form, when requested by us, to report the progress of patients participating in gym, swimming and pilates programs funded by us as part of their rehabilitation.

Home modifications assessment form (for Provider use only)

For occupational therapists – complete this comprehensive form when providing assessment services for our clients when they are applying to us for home modifications to ensure safety and accessibility.

Note: there are separate forms for Hospital based OTs and for Community based OTs.

Home services needs assessment referral form (for Provider use only)

For medical and health providers – complete this form when requesting an occupational therapist assessment of the functional capacity and needs of clients who are unable to perform their usual household duties and responsibilities due to their transport accident injuries.

Home services needs assessment report form (for Provider use only)

For occupational therapists – complete this form when assessing the functional capacity and needs of clients who are applying to us for home services because they are unable to perform their usual household duties and responsibilities due to their transport accident injuries.

Hospital Claim Form (for Hospital use only)

For hospitals – use this claim form to lodge a claim with us when a patient is in hospital after a transport accident.

With permission from the patient, you can help the patient complete the claim form and submit the claim directly to us via secure email or fax number (03) 9656 9437.  By completing this form, the patient is submitting a claim to us to assess their entitlements.

We will then make a decision about the claim and notify the patient. If the claim is accepted, the patient will be allocated a TAC claim number.

If the patient does not complete the form while in hospital, but would like to lodge a claim at a later date, they can phone us directly on 1300 654 329.

Hospital direct equipment order form

For hospitals – use this form to directly order equipment from our contracted suppliers when required to facilitate the effective discharge of the patient.

Items valued up to $1,000 can be ordered, and the patient must have an accepted TAC claim. Follow the instructions in the form to ensure orders are processed without delay.

The equipment listed on the form are the most commonly required to ensure a patient's safe discharge, although any item can be ordered from our contracted supplier. Requests for equipment over $1,000 need to be made in writing to us.

Individual plan and outcome report form

For case managers – use this form to record, and assess progress of, a client’s independence plan, in conjunction with the TAC Support Coordinator. The aim of an independence plan is to maximise client independence and help them achieve health, vocational and quality of life goals.

For help completing this form, see the separate notes document.

Integration support: aide account form

For schools – complete this form for payment or reimbursement of approved education support services provided by aides to assist a student who is our client.

Integration support: billing information

For schools – this information sheet will help school bursers complete documentation regarding students with funded education support, such as aides or tutoring time, that is funded by us.

Integration support: goal development worksheet

For schools – use this worksheet to record the goals of students who are TAC clients and require education support.

Integration support: teacher account form

For schools – complete this form to claim payment/reimbursement of an integration teacher funded by us to assist a student who is our client.

Living in the community assessment form

For case managers – in consultation with your client, use this form to prepare for living in the community after hospital. To ensure a safe and smooth transition, the assessment looks at the client's daily routine, interests, support network and tasks that they might need assistance with.

For help completing this form, see the separate notes document.

Mental health (neuropsychology): treatment plan

For registered psychologists – when our clients have a cognitive, behavioural and/or mental health condition caused by their transport accident, complete this form to request funding beyond an initial neuropsychological assessment. You will need to provide details of current neuropsychological status, risk factors and a proposed care plan and progress measures.

For help completing this form, see the separate notes document.

Mental health (neuropsychology): treatment review form

For registered psychologists – when requested by us, complete this form to report on the progress and/or effectiveness of our client’s neuropsychology treatment plan. This form should also be used when the treating practitioner anticipates significant variations to a client's condition, goals, or the duration and amount of treatment required.

For help completing this form, see the separate notes document.

Mental health (psychology): treatment plan

For registered psychologists – complete this form, when requested by us, when our clients have a mental health condition caused by their transport accident. You will need to provide details of current diagnosis, risk factors and a proposed care plan and progress measures.

For help completing this form, see the separate notes document.

Mental health (psychology): treatment review form

For registered psychologists – when requested by us, complete this form to report on the progress and/or effectiveness of our client’s mental health treatment plan. This form should also be used when the treating practitioner anticipates significant variations to a client's condition, goals, or the duration and amount of treatment required.

For help completing this form, see the separate notes document.

Network Pain Management Program: Request for Assessment form

For medical practitioners, physiotherapists and psychologists – use this form to request an assessment for a TAC client by a Network Pain Management Program provider.

Network Pain Management Programs can help manage musculoskeletal injuries and persistent pain to improve enjoyment of life and increase independence.

Orthotics device request form

For medical and health providers – use this form to request orthotic devices when over $1,000. You will need to provide details of the orthotic devices you need, and the associated clinical services to improve the function and mobility of your patient.

Osteopath: questionnaire form

For osteopaths – use this form, when requested by us, to provide an overview of your treatment of our clients, including functional limitations, treatment goals, outcome measures and self-management strategies.

For help completing this form, see the separate notes document.

Outpatient Rehabilitation plan form

For rehabilitation facilities – complete this form to prepare your client for their outpatient therapy program. It sets goals for the client and outlines the action plan that will help them achieve these aims.

For help completing this form, see the separate notes document.

Overseas Attendant Care Request form (for Provider use only)

For occupational therapists – complete this form, in consultation with a community access planner and your client, to request support for your client while overseas on holiday.

Pain management service: inpatient multidisciplinary assessment form

This form is for completion by the multidisciplinary team assessing the pain management needs of a TAC client who is a hospital inpatient to help them manage their condition and reduce the disability associated with pain. The assessment takes into account the patient's physical and emotional functioning.

Pain management service: outpatient multidisciplinary assessment form

This form is for completion by the multidisciplinary team assessing the pain management needs of a TAC client who is a hospital outpatient to help them manage their condition and reduce the disability associated with pain. The assessment takes into account the patient's physical and emotional functioning.

Pharmacy: erectile dysfunction questionnaire

For medical practitioners – complete this form to provide us with information on your patient’s erectile issues. We will then be able to determine if we can pay for your client’s erectile dysfunction medication.

Physiotherapy: management review (PMR) form

For physiotherapists – use this form, when requested by us, to report on the progress and/or effectiveness of your client's physiotherapy treatment, prognosis and self-management plan.

For help completing this form, see the separate notes document.

Physiotherapy: treatment notification plan (TNP) form

For physiotherapists – complete and submit this form only if we request a TNP.

A Treatment Notification Plan (TNP) reports on your client's clinical diagnoses, proposed treatment plan, self-management strategies and outcome measures.

For help completing this form, see the separate notes document.

Post Acute Support/Attendance Services declaration

Attendant care providers – use this form to log and declare the dates and hours of service.

Attendant care providers support our clients to achieve their independence goals in daily living activities, therapy support, personal and domestic skills retraining and community access skills.

Prosthetics: management review lower extremity form

For prosthetists and orthotists – use this form, when requested by us, to review your client’s prosthetic management and measure progress against the predicted outcomes that were specified in the initial Prosthetic Treatment Request Form. This form is specifically for clients who have a lower extremity prosthetic device.

For help completing this form, see the separate notes document.

Prosthetics: management review upper extremity form

For prosthetists and orthotists – use this form, when requested by us, to review your client’s prosthetic management and measure progress against the predicted outcomes that were specified in the initial Prosthetic Treatment Request Form. This form is specifically for clients who have a upper extremity prosthetic device.

For help completing this form, see the separate notes document.

Prosthetics: treatment request form

For prosthetists and orthotists – use this form to request prosthetic treatment, new prosthetic devices, major repairs and changes of prescription when over $1,000. You will need to provide details of the proposed prothesis prescription and information to support the requested services and hours.

For help completing this form, see the separate notes document.

Referral form (for Outreach, Case Management and MACNM services)

The form is to be used when referring a TAC client to any of the following services:

  • Outreach Services
  • Case Management
  • Multiple and Complex Needs Model (MACNM)

Return to work: plan form

This form sets out the return to work plan for TAC clients to ensure the process is safe, coordinated and smooth. The plan details the worksite assessment, goals, projected hours and duties for the program's initial phase. The document needs to be completed by the therapist in consultation with the client and employer, then submitted to the TAC at last five days before the program commences.

Sedative Management Plan (SMP) form

For treating professionals – complete this form, when requested by us, to plan and manage the use of sedatives, to ensure the safety and wellbeing of our clients when they take this medication. It includes strategies to minimise sedative use and avoid misuse or addiction.

Sleep Disordered Breathing & CPAP Questionnaire

For medical practitioners – use this form, when requested by us, to report on sleep disordered breathing difficulties when experienced by our client as a result of their accident. The form seeks details of the medication and treatment given to date, as well as relevant health and lifestyle information.

Special education: Assessment and recommendations form

For schools – use this form to capture the assessment and recommendations, proposed goals and outcomes for our school-age clients who are seeking funding for special education or therapy services.

Special education: Review and request ongoing services form

For schools – use this form to report on the progress of school-age clients  receiving special education services. It looks at how much improvement the client has made, based on the proposed outcomes recorded in the initial Assessment and Recommendations form, and asks for revisions to the special education intervention plan, goals and strategies.

Speech pathology: management review plan (SPMR) form

For speech pathologists – complete this form, when requested by us, to report on the progress and/or effectiveness of your patient's speech pathology treatment and management plan. You will need to outline how much improvement the patient has made and propose any revisions to the treatment plan, goals and strategies.

For help completing this form, see the separate notes document.

Speech pathology: treatment notification plan (SPTNP) form

For speech pathologists – prepare and submit a Treatment Notification Plan (TNP) only when requested by us. The plan requires a clinical diagnoses, proposed treatment plan, self-management strategies and outcome measures.

For help completing this form, see the separate notes document.

TAC freedom of information (FOI) application form - represented client

For clients and client representatives – use this form to submit a request to us to view or obtain copies of documents under Freedom of Information laws.

Transport needs assessment form (for Provider use only)

For providers – use this form to assess transport needs for our clients as a result of their accident injuries. You will need to consider transport requirements in relation to travelling to work, school, treatment/rehabilitation, recreational activities and day-to-day tasks such as shopping and banking, as well as provide recommendations as to how we can assist.

Travel expenses: declaration for carers (for Provider use only)

For attendant carers – use this form to declare travel expenses incurred when your vehicle is used to transport your patient to medical appointments.

Tutoring support: account form

For Schools – use this form to detail the hours of approved education support services provided by tutors to assist our client.

Urgent psychiatric admission: Request for funding form

For registered medical practitioners – complete this form to request urgent psychiatric admission for our client.

The form requires a clinical diagnoses of the client's condition and an explanation of why the admission is needed urgently.

Vehicle needs and modifications assessment form (for Provider use only)

For Occupational Therapists – complete this form to submit applications for TAC-funded vehicle modifications, to ensure the safety, accessibility and independence of our clients as drivers or passengers.

You will need to provide details about the person's transport needs, as well as whether their current or pre-accident vehicle is suitable for modification and, where relevant, if it has the capacity to fit a wheelchair.

Victorian Paediatric Rehabilitation Services (VPRS) discharge summary

For VPRS – complete this form when our client, of child or adolescent age, is being discharged from VPRS care. The form records the client’s ongoing care and rehabilitation plans.

Vocational Rehabilitation Suspension Report

For hospitals – use this form when vocational assistance to our clients needs to be suspended.

Suspensions should only occur after discussion with us.

Brochures

Billing review program information sheets

We conduct periodic reviews of payments made to our medical and allied health service providers through our Billing Review Program. The primary focus is to ensure that payments made to providers are appropriate and comply with TAC policies and fee schedules.

Clarification of Medicare Benefits Schedule (MBS) rules

We pay for medical services in line with the Medicare Benefits Schedule (MBS) items, explanations, definitions, rules and conditions, unless otherwise specified. Here’s what we can and cannot pay for, in relation to specific MBS item combinations.

Client Independence Skills Service (CISS) information sheet

An introduction to Client Independence Skills Service (CISS). CISS is a time limited and goal directed skill development service that’s suitable for clients who have active life area goals and want to develop their skills and gain independence.

Client Independence Skills Service (CISS) provider list

A list of Client Independence Skills Service (CISS) registered providers, including the regions they service and their contact details. These providers are authorised to provide CISS services to our clients.

CMSO (Complex and Multi-site Orthopaedic Injuries)


This document outlines to Physiotherapists the TAC's Complex and Multi-site Orthopaedic injuries criteria

General Practitioner Participation in Return to Work Activities factsheet

Here’s how you can help your patient to stay at work, or facilitate their return to work, after a transport accident. The best way to support them is to keep everyone talking - the patient, the employer, the rehabilitation or vocational provider and the TAC claims coordinator.

GST compliance information sheet

To meet tax requirements, providers must include specific information on invoices – and requirements differ depending on the amount being billed. This information sheet explains how to make sure your invoice includes the required details.

Independence Plan - Information for providers

As medical and health providers, you play a critical role in helping your seriously injured client maximise their independence and achieve their goals. The Independence Plan documents the work done by you and other members of the treating team, and acts as a central reference point for everyone.

Network Pain Management Programs - Information for Medical Practitioners, Physiotherapists and Psychologists

Network pain management programs aim to help our clients manage their musculoskeletal injuries and persistent pain, and increase their independence. This information sheet, for medical practitioners, physiotherapists and psychologists, explains the benefits and the referral process.

Outreach Provider contact list

The Outreach Service (OS) supports clients with psychosocial or mental health issues, behaviours of concern and other support needs. This list of registered outreach providers includes contact details and the regions they service.

Protocols Legal Costs

These documents outline the legal costs payable to legal practitioners for matters resolved under our protocols. Impairment, no fault and common law protocols are included.

Reimbursement Rates for Medical Services Information Sheet

This Information sheet provides an introduction to TAC's fee schedule for Medical Practitioners.

VPRS and TAC Communication Guidelines

The TAC and the Victorian Paediatric Rehabilitation Services (VPRS) provide support to children in different ways after a transport accident. This document aims to help the two entities to work together.