Rehab at Home Extension request

Instructions

Use this form to request the extension of rehabilitation at home services for a TAC client. Complete only if you have registered with the TAC to deliver these services.

Required fields are marked with an asterisk (*).
TAC client details
Primary injury for rehabilitation/treatment
(if options available above don't provide enough information)
Pre-existing co-morbidities
(please specify)
Goals and outcome measures
EQ-5D-5L scores
Rehabilitation goals
Rehabilitation goal 1
Rehabilitation goal 2
Rehabilitation goal 3
Rehabilitation goal 4
Rehabilitation goal 5
Outcome measures

Measurable goals e.g. attend local shops by increasing walking distance
Measurable tool e.g. six-minute walk
Current Measurable score e.g. 100m

Goal 1
(e.g. attend local shops by increasing walking distance)
Goal 2
Goal 3
Goal 4
Goal 5
Details for extensions
Frequency/type of services being requested
Therapy 1
Therapy 2
Therapy 3
Therapy 5
Therapy 4
Expected progress with extension against client's rehabilitation goals
Rehabilitation goal 1
Rehabilitation goal 2
Rehabilitation goal 3
Rehabilitation goal 4
Rehabilitation goal 5
Expected progress with extension against client's outcome measures
Goal 1
(e.g. attend local shops by increasing walking distance)
Goal 2
Goal 3
Goal 4
Goal 5
Provider details

Privacy

The TAC will retain the information provided and may use or disclose it to make further inquiries 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 website at www.tac.vic.gov.au