Allied Health Treatment and Recovery Plan - TAC - Transport Accident Commission

Client details

Client's first name *

Client's last name *

Claim number *

Date of birth (dd/mm/yyyy) *

Date of accident (dd/mm/yyyy) *

Occupation

Current work status *

Normal duties
Modified duties
Not working
Not applicable

Injury details * Diagnosis and specific areas being treated

Outcomes You must supply the standard outcome measures used.

First Outcome measure used

Outcome measure *

Initial date (dd/mm/yyyy)

Initial score

Subsequent date (dd/mm/yyyy)

Subsequent score

Next subsequent date (dd/mm/yyyy)

Next subsequent score

Latest date (dd/mm/yyyy)

Latest score

Add additional outcome measure

Second Outcome measure

Outcome measure

Initial date (dd/mm/yyyy)

Initial score

Subsequent date (dd/mm/yyyy)

Subsequent score

Next subsequent date (dd/mm/yyyy)

Next subsequent score

Latest date (dd/mm/yyyy)

Latest score

Add 3rd outcome measure

Third Outcome measure

Outcome measure

Initial date (dd/mm/yyyy)

Initial score

Subsequent date (dd/mm/yyyy)

Subsequent score

Next subsequent date (dd/mm/yyyy)

Next subsequent score

Latest date (dd/mm/yyyy)

Latest score

Screening Screening of psychosocial risk factors (barriers) to recovery

Psychosocial screening tool

(E.g. Ӧrebro short form – see notes page)

Screening date (dd/mm/yyyy)

Score

Actions taken

Issues/risks identified that may impact recovery and return to work, if any

List any barriers that you have recognised and the steps you have taken or will be taking to address them.

Goals of your treatment List current activity/functional limitations and related goals that your treatment will address.

Goal 1

Current activity/functional limitations *

Short term activity goals * Include ADL and work/travel goals

Estimated date of achievement (dd/mm/yyyy) *

Add 2nd goal

Goal 2

Current activity/functional limitations

Short term activity goals Include ADL and work/travel goals

Estimated date of achievement (dd/mm/yyyy)

Add 3rd goal

Goal 3

Current activity/functional limitations

Short term activity goals Include ADL and work/travel goals

Estimated date of achievement (dd/mm/yyyy)

Add 4th goal

Treatment strategies *

Self management strategies *

Include an itemised list of all therapy support items you have provided to the client to assist with their rehabilitation needs.

Total number of services * over how many weeks *

From (dd/mm/yyyy) *

to (dd/mm/yyyy) *

Do you have an anticipated discharge date for this patient? *

Your details

Provider / Treater name *

Employer/Organisation you work for *

Address *

Suburb *

Postcode *

Phone number *

Email address *

Availability for discussion

Acknowledgement

I have discussed this treatment plan with my patient and I agree to discuss this plan with members of the TAC clinical panel as required. I understand that I can only bill the TAC for treatment that is directly related to my patient’s transport accident.

Your privacy

The TAC will retain the information provided and may use or disclose it to make further enquiries to assist in the ongoing management of the claim or any claim for common law damages. The TAC may also be required by law to disclose this information.
Without this information, the TAC may be unable to determine entitlements or assess whether the treatment is reasonable and may not be able to approve further benefits and treatment.
If you require further information about our privacy policy, please call the TAC on 1300 654 329 or visit our privacy policy.

Su	Mo	Tu	We	Th	Fr	Sa
1	2	3	4	5	6	7
8	9	10	11	12	13	14
15	16	17	18	19	20	21
22	23	24	25	26	27	28
29	30