Forms

Most requested provider forms

Forms

Above Rate Service Agreement

Complete this form if you are a registered TAC provider currently delivering services to TAC clients and want to apply for an Above Rate Service Agreement.

Allied Health Treatment and Recovery Plan

For allied health providers – complete this form, when requested by us, to provide an overview of a client's injury, outcome measures and goals. For ongoing treatment to be approved, it must be clinically justified by satisfying the five principles of the Clinical Framework. For help completing this form, see the separate notes document.

Complete the Allied Health Treatment and Recovery Plan form online

Assistive technology assessment and recommendations

Complete this form to recommend assistive technology to support a person's goals. To request customised items, attach a quote from the TAC equipment contractor – either our quote template or the contractor's own format (if it supplies the same information as our template).

Attendant Care Overnight Task Log

For support workers – Complete this task log when requested by us to demonstrate the time and tasks undertaken during active support hours, particularly when transitioning from an inactive sleepover shift to active support.

Audiology - Hearing assessment and device request form

For audiologists – Complete this form to request hearing devices for a TAC client. Include clinical notes and hearing assessment information.

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. See the form introduction for the information and documents that need to be provided.

Care Online access request

For attendant care providers – Use this form to request access to the Care Online electronic payment system.

Certificate of Capacity form

The Certificate of Capacity is for authorised providers to provide information about a TAC client’s transport accident conditions and to assess and certify their capacity for work as a result of these injuries. Feedback about this form can be emailed to medicalcertificatefeedback@tac.vic.gov.au

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.

Common Law Time limit protocols

Community access and transport assessment recommendations

For occupational therapists – complete this form to identify goals for community access and the most appropriate transport solutions.

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

For medical practitioners and allied health providers – Use this form when a client with physical, sensory and cognitive disabilities needs support to participate in recreational and leisure activities.

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

For medical practitioners and allied health providers – Complete this plan to identify progress and outcomes related to the client's 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 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 this form to provide an overview of a client’s activities and 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 – complete this form to request continence equipment for your patient. Provide a summary of the continence assessment along with your recommendations. For help completing this form, see the separate notes document.

Also complete this form when a major review of the continence equipment requirements is conducted (usually every two years) or there has been a change to the continence regime.

Continence equipment prescription and order form: Hospital discharge

For hospital continence nurses – complete this form to request continence and related equipment for patients transitioning to the community. Provide a summary of the continence issues and routine along with suggested goals. For help completing this form, see the separate notes document.

Also complete this form when a major review of the continence equipment requirements is conducted (usually every two years) or there has been a change to the continence regime.

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 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 – complete this plan to request educational support services, outlining 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. Read this form 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. Read this form in conjunction with Rehab Online documentation.

Equipment prescription form

Please use the Assistive technology assessment and recommendations form to recommend assistive technology / equipment items.

Exit Report (for Outreach, Case Management or MACNM services)

For outreach, case management and MACNM (Multiple and Complex Needs Model) service providers – complete this report upon closure of services with a TAC client, providing information about their progress, outcomes achieved, future risk management and further support needs.

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 clients participating in gym, swimming and pilates programs funded by us as part of their rehabilitation.

Holiday support plan

For occupational therapists – complete this form to request funding to meet a person’s support needs required for a holiday.

Home modifications assessment and recommendations

For occupational therapists – to access this form please contact the TAC Home Modifications team at home_modifications@tac.vic.gov.au.

This form is used to assess if home modifications are required to maximise a person’s safety and capabilities in their home. Approval and discussion with a TAC home modifications officer must be obtained prior to completing a home assessment.

Home services assessment and plan

For occupational therapists – complete this form to describe the capabilities and needs of a person who has requested home services.

Home services review

For occupational therapists – complete this form to review supports that help a person manage day-to-day tasks in their home.

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 form's instructions 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 suppliers. Requests for specialised equipment need to be made in writing to us.

Initial occupational therapy assessment

For occupational therapists – complete this form to establish an OT plan and request funding to provide services to a TAC client.

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 a student who is our client and requires 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.

Medical and pharmacy questionnaire

For General Practitioners - Please only complete at the TAC's request. You can use this form to help the TAC review a request for medication.

Medicinal Cannabis for Chronic Non Cancer Pain (CNCP) request form

For Medical Practitioners - This form must be completed for all requests of medicinal cannabis to treat chronic non-cancer pain (CNCP).

Complete in full and provide copies of all relevant documents. The TAC cannot consider requests for medicinal cannabis without the full completion of this form. If a Pain Specialist is not involved in the patient’s pain management, we are unable to consider funding this request.

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.

Occupational therapy review of capabilities

For occupational therapists – complete this form to review a person’s capabilities and required supports.

Occupational therapy service plan review

For occupational therapists – complete this form to report on whether intervention is complete or if further OT services are needed.

Occupational therapy supported accommodation review of capabilities

For occupational therapists – complete this form to review a person’s capabilities and supports relating to supported accommodation.

Opioid Safety and Management

For treating professionals – when requested by us, complete either the:

Opioid Safety Check or
Opioid Management Plan

This information helps ensure the safe provision of opioids and other high-risk medications. See details at opioid management.

Orthotics device request form

For medical and health providers – use this form to request specialised orthotic devices. Provide details of the orthotic devices needed and the associated clinical services to improve the function and mobility of our client.

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.

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. The aim is to help them manage their condition and reduce the disability associated with pain, taking into account their 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. The aim is to help them manage their condition and reduce the disability associated with pain, taking into account their physical and emotional functioning.

Pharmacy: erectile dysfunction questionnaire

For medical practitioners – complete this form to provide information on a client's erectile issues. This will allow us to determine if we can pay for their erectile dysfunction medication.

Progress Report (for Outreach, Case Management or MACNM services)

For outreach, case management and MACNM (Multiple and Complex Needs Model) service providers – complete a report and submit it every three months to the client’s TAC Coordinator. This provides us with information on the client's progress and serves as the basis for follow-up discussions with us in person or over the phone.

Prosthetics: management review lower extremity form

For prosthetists and orthotists – use this form when requested by us to review a client’s prosthetic management and measure progress against the predicted outcomes specified in the initial treatment request. 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 a client’s prosthetic management and measure progress against the predicted outcomes specified in the initial treatment request. This form is specifically for clients who have an 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. Provide details of the proposed prosthesis prescription and information to support the requested services and hours. For help completing this form, see the separate notes document.

Provider registration

Health and service providers – To provide your services to our clients, please complete this registration form online or in PDF format.

Online provider registration form

Rehabilitation at home discharge form

For rehabilitation at home service providers – use this form to provide details on the discharge of a TAC client from rehabilitation at home services. Complete only if you have registered with the TAC to deliver these services.

Rehabilitation at home extension request

For rehabilitation at home service providers – use this form to request the extension of rehabilitation at home services for a TAC client. Please send this request as soon as you anticipate further services will be required. Complete only if you have registered with the TAC to deliver these services.

Rehabilitation at home initial assessment

For rehabilitation at home service providers – use this form to request rehabilitation at home services for a TAC client. Complete only if you have registered with the TAC to deliver these services.

Release of information solicitors forms

For solicitors – Use this form to request a release of information from the TAC.

Repetitive transcranial magnetic stimulation request

Psychiatrists – use this form to request repetitive transcranial magnetic stimulation (rTMS) for a TAC client needing acute treatment in an outpatient setting, maintenance treatment in an outpatient setting, or treatment in an inpatient setting.

Return to work: plan form

This plan helps ensure that the return-to-work process for a client is safe, smooth and coordinated. It details the worksite assessment, goals, projected hours and duties for the program's initial phase. The plan needs to be completed by the therapist in consultation with the client and employer, then submitted to us at least five days before the program starts.

Ride-on mower assessment and recommendations

Occupational therapists – complete this form for all requests for ride-on-mowers and like vehicles (e.g. side-by-side and farm utility vehicles) and related equipment (e.g. tow-behind weed sprayers and trailers) for a TAC client.

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.

Shared Supported Accommodation Property Enrolment Application

For shared supported accommodation service providers – complete this form to enrol a property for supported accommodation services.

Shared Supported Accommodation Provider Registration

For shared supported accommodation service providers – complete this form to register to provide supported accommodation services.

Sleep Disordered Breathing & CPAP Questionnaire

For medical practitioners – use this form when requested by us to report on sleep disordered breathing difficulties experienced by a client as a result of their accident. It asks for details of the medication and treatment given, 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 a school-age client 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 a school-age client receiving special education services. It looks at the client's improvement based on the proposed outcomes from the initial assessment and recommendations, 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 effectiveness of a client's speech pathology treatment and management plan. Outline their improvement 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 this plan only when requested by us. Include clinical diagnoses, proposed treatment, self-management strategies and outcome measures. For help completing this form, see the separate notes document.

Surgery request form

For surgery practices – this form is our preferred method for surgery practices to request TAC approval for surgical procedures, including injection procedures. It asks for information we need to make a decision on the surgery request and understand more about how it relates to the client’s transport accident and expected outcomes. Please submit any questions or feedback via our online contact us form.