Forms

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

Most requested provider forms and brochures

Forms

Allied Health Treatment and Recovery Plan

For allied health providers – complete this form, when requested by us, to provide us with an overview of your patient’s injury, outcome measures, goals and other details. For help completing this form, see the separate notes document.

For ongoing treatment to be approved, it must be clinically justified by satisfying the five principles of the Clinical Framework for the Delivery of Health Services.

Complete the Allied Health Treatment and Recovery Plan form online

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

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.

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 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.

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.

Important:
Approval from TAC/WorkSafe agent must be obtained prior to completing a home assessment.

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.

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

This form is to be completed by occupational therapists reviewing the functional capacity and needs of clients currently receiving TAC-funded homes services and evaluating their progress towards independence. The assessment also takes into account feedback form the client's General Practitioner and other relevant treaters.

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.

Basic equipment items 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 items 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 specialised equipment 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: 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 (psychology and neuropsychology): treatment plan

For registered psychologists / neuropsychologists – complete this form for new clients who require more than the six pre-approved services or when requested by us.

Complete the Mental Health (Psychology) Treatment Plan form online

Complete the Mental Health (Neuropsychology) Treatment Plan form online

Network Pain Management Program: Comprehensive Report and Ongoing Management Plan

For Network Pain Management Program providers – use this form to record ongoing management of TAC clients.

Network Pain Management Program: Follow Up Report and Plan

For Network Pain Management Program providers – use this form to record a follow-up report and plan for TAC clients.

Network Pain Management Program: Non-Completion of Program Report

For Network Pain Management Program providers – use this form to report on the non-completion of a program by a TAC client.

Orthotics device request form

For medical and health providers – use this form to request specialised orthotic devices. 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.

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 Opioid Management Plan

For treating professionals – complete this form, when requested by us, to plan and manage the use of opioids, to ensure the safety and wellbeing of our clients when they take this medication. We also need this information to ensure ongoing compliance with state and federal regulations for the prescription of opioid medications that are funded by the TAC.

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.

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. 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.

Provider registration and change of EFT forms

For existing health and service providers – use the EFT form 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.

If you would like to provide your services to our clients, please register using our online registration form.

Online provider registration form

Manually completed provider registration forms can be returned to the TAC via:

Email: info@tac.vic.gov.au
Fax: 03 9656 9533
Post: Data Maintenance, Transport Accident Commission, 
GPO Box 2751 Melbourne, Victoria, 3001

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 – This form should only be completed upon referral from the TAC post the completion of a Transport Needs Assessment Form. 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.

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.