Workers Health Centre Consent Form "*" indicates required fields I authorise the Workers Health Centre (Rehabilitation Provider) to OBTAIN and RELEASE information concerning relevant aspects of my rehabilitation program, and to discuss that information with representatives of the agencies nominated below:Provider Employer Doctor Insurance Company Union Referrer Solicitor Psychologist Physiotherapist/Exercise Physiologist. Other The information provided will be of factual nature concerning the rehabilitation program and may also include electronic transmission.I authorise the Workers Health Centre (Rehabilitation Provider) to use my records file in an audit.I understand that I may change or cancel this authority at any time.Name* Consent* I agree to the below statement.*I am aware that in certain circumstances, some organisations are legally entitled to receive rehabilitation information about an injured worker- for example the insurer, the State Insurance Regulatory Authority and a NSW Court of LawNote: Fact sheets are available at the bottom of this page.Signature of Injured WorkerCAPTCHANameThis field is for validation purposes and should be left unchanged.
