Joint Medical Examination Request Form

If you wish to submit a manual request form, please refer to the forms on the JME Protocols page.


Client Details

Note. claim no. format – XX/XXXXX
Is this client under the age of 18 years old? (required)
Does this client have any additional claims with the TAC? (required)
Claim Number Please check box if relevant to this exam
Please check box 1 if relevant to this exam
Please check box 2 if relevant to this exam
Please check box 3 if relevant to this exam

Solicitor Details

Note. email format – example@email.com

Request Type - Please select one of the following

Request Type (required)

Requested Joint Medical Examinations 1

Appointment date
Appointment time :

Medical Examiner details

Practice/Medical centre address

Once you have arranged the medical examination(s), please complete the ‘Pre-Approved Joint Medical Examination Booking Form’ available here

Requested Joint Medical Examinations 2

Appointment date
Appointment time :

Medical Examiner details

Practice/Medical centre address

Requested Joint Medical Examinations 3

Appointment date
Appointment time :

Medical Examiner details

Practice/Medical centre address

Requested Joint Medical Examinations 4

Appointment date
Appointment time :

Medical Examiner details

Practice/Medical centre address

Requested Joint Medical Examinations 5

Appointment date
Appointment time :

Medical Examiner details

Practice/Medical centre address

Requested Joint Medical Examinations 6

Appointment date
Appointment time :

Medical Examiner details

Practice/Medical centre address

Where possible please attach the instruct letter or any relevant documentation not previously provided to the TAC

They can be a maximum of 3 mb each and any of the following file types - doc docx png jpg gif xls pdf

^Inform the TAC if your client has travel or interpreter requirements

^^This is the published TAC JME  Request form

By submitting this form you are agreeing to comply with the JME Process 1 July 2014 and any other processes published by the TAC in relation to JMEs. Acceptance of the JME request and any subsequent change requests are on the condition that you continue to comply with the JME Process 1 July and any process that replaces or modifies it and any other processes published by the TAC in relation to JMEs. Failure to comply may result in the medical examination not qualifying for reimbursement under section 60(2F) of the Transport Accident Act 1986 (Vic).