COMMONWEALTH OF AUSTRALIA
Safety, Rehabilitation and Compensation Act 1988
SECTIONS 34K and 34S
APPROVED FORM FOR APPLICATION FOR RENEWAL OF APPROVAL AS A REHABILITATION PROGRAM PROVIDER
Comcare, pursuant to paragraph 34K(1)(a) and subsection 34S(1) of the Safety, Rehabilitation and Compensation Act 1988, approves the following form as the approved form for the purposes of persons applying under section 34J for renewal of approval as a rehabilitation program provider. This approval applies on and from 1 November 2006.
Dated 29 September 2006
The seal of Comcare was affixed
in the presence of:
Barbara Bennett
Chief Executive Officer
Renewal Application Form pages 1- 13 attached
Safety, Rehabilitation and Compensation Act 1988
APPLICATION FORM
FOR
RENEWAL OF APPROVAL
AS A
REHABILITATION PROGRAM PROVIDER
This application form is an approved form for the purposes of section 34S of the Safety, Rehabilitation and Compensation Act 1988 and is to be completed by approved rehabilitation providers seeking renewal of approval under sections 34J and 34K of the Act.
INFORMATION ON COMPLETING
THE RENEWAL APPLICATION
1. Approved Rehabilitation Providers (providers) may apply to Comcare for renewal of approval as a rehabilitation program provider. The application must be in writing in the approved form and be accompanied by the prescribed fee.
2. The renewal process is a combination of self assessment and comparative performance measurement based on Comcare’s Criteria for Initial Approval or Renewal of Approval of Rehabilitation Program Providers (the criteria) and Comcare’s Operational Standards for Rehabilitation Program Providers (the standards). The standards consist of both outcome standards and service standards.
3. Comcare will renew the approval of the provider under section 34L of the Safety, Rehabilitation and Compensation Act 1988 (the SRC Act) where Comcare is satisfied that the provider:
(a) meets the criteria
(b) has demonstrated compliance with the standards in force since the applicant was initially approved or last renewed, and
(c) is likely to meet the standards in force with effect from the renewal date.
The renewal process
4. There are three stages in the renewal process:
(a) provider completes the application for renewal (including the self-assessment tool)
(b) Comcare assesses the application and the provider’s performance against Comcare’s operational standards, and
(c) Comcare issues a written decision renewing, renewing with conditions or refusing to renew the provider’s approval.
The provider application
5. Complete Section 1 furnishing your correct entity details.
6. Complete Part One which examines whether the provider continues to meet Comcare’s existing criteria for approval, furnishing any required documentation.
7. Part Two of the application requires the provider to conduct a self assessment of five SRC Act cases or 10 per cent of their total caseload, whichever is greater to test compliance with the Comcare’s current service standards. Comcare randomly selects the cases for assessment from the provider’s return to work plans that have been closed during the relevant period.
8. This part also requires providers to describe aspects of their return to work process or those processes they plan to adopt to meet new service standards in force from 1 July 2007, the renewal date.
9. Throughout this process Comcare may consult with the provider and may at any time request further information in writing from the provider.
Lodgement of application form
10. The provider should lodge the application or advise that they do not wish to seek renewal by 1 December 2006. Comcare will accept applications where the applicant can provide proof of lodgement by post prior to 31 December 2006. Comcare will acknowledge receipt of the application in writing.
11. Late applications may only be considered in exceptional circumstances [see s34J(3) of the SRC Act].
Integrity of the renewal process
12. To ensure the integrity of the self-assessment process, Comcare may conduct audits of randomly selected providers to assess the completion of the self-assessment tool.
Outcome standards assessment
13. Comcare will conduct an assessment of each provider’s performance in respect of their current period of approval against the following outcome standards:
(a) return to work rate (as a percentage)
(b) median cost of return to work plans (in dollars), and
(c) median duration of return to work plans (in weeks).
14. Benchmark outcome standards for each of these standards have been determined by Comcare. The outcome standards are published on Comcare’s website and are available in the publication ‘Standards for Approved Rehabilitation Providers’.
15. Comcare will calculate each provider’s RTW rate, cost and duration based on all closed return to work plans for the relevant period. The results will then be assessed for compliance against each standard’s performance measure.
Service standards assessment
16. Comcare will examine the provider’s record of meeting the current service standards through the provider’s self assessment of compliance (which may be subject to random audit by Comcare) based on a nominated sample of files. Comcare will also examine the provider’s description of its return to work processes to form a view on whether it will be likely to meet the operational standards in force from the renewal date, 1 July 2007.
Where a provider has failed to meet a standard
17. If a provider identifies poor performance against a standard during the self-assessment process, the provider must attach an explanatory statement at the time of submitting the application. Comcare considers performance by a provider against each individual standard within the context of overall performance against all standards.
18. Factors which may be considered include servicing remote areas, managing complex injuries, assisting with redeployment and late intervention cases.
Renewal of approval
19. If Comcare is satisfied, having regard to the information in the application, or any additional information supplied, that the provider meets the application criteria and has demonstrated compliance with the operational standards in force since the provider was initially approved or last renewed and is likely to meet the operational standards from the renewal period, it will renew the approval of the provider for a period of three years and inform the provider of its decision in writing.
20. Comcare may also grant a conditional renewal of approval. The provider would be advised of the conditions and their review rights in writing.
21. If Comcare refuses to renew the applicant’s approval, the provider will be advised of the reasons and their review rights in writing.
Section 1 – Application form for renewal of approval as a rehabilitation program provider
| If you WISH TO SEEK RENEWAL please fill out the details below. Complete the application and return it to Comcare by 1 December 2006. |
| Name of Approved Rehabilitation Provider | |
| What is your Australian Business Number (ABN)? And does this match with your approved entity status with Comcare? |
Attach copy of the ABN record from the Australian Business Registry. Go to www.abr.business.gov.au to find your ABN record. |
| What is your Comcare approved rehabilitation provider number/s? | ACT | | SA | |
| NSW | | WA | |
| QLD | | NT | |
| VIC | | TAS | |
| Are you a sole trader? | Sole trader name: |
| Are you a partnership? | Name of all partners |
| Are you a company? · Full name of company including trading name · ACN · Names of all principals · Name and address of parent organisation, if applicable. | |
| Business address – street | |
| Business address – postal (if different) | |
| Business phone number | |
| Fax number | |
| Email | |
| Contact person for this application · Name · Phone · Email | |
| If you DO NOT WISH TO SEEK RENEWAL please fill out the details below and send only this page to Comcare. Fax 02 6221 5564 or to the address stated below by 1 December 2006. |
| Not seeking renewal of approval (please tick) □ |
| Name of Approved Rehabilitation Provider | |
| What is your Comcare approved rehabilitation provider number/s? | ACT | | SA | |
| NSW | | WA | |
| QLD | | NT | |
| VIC | | TAS | |
| Business address – postal | |
| Your name and title | |
| Signature | |
Please return to: Approved Rehabilitation Providers – Renewal
Comcare
GPO Box 9905, Canberra ACT 2601
Complete the following questions in relation to you as a provider since 1 July 2004 (or from the date of your initial approval if after 1 July 2004):
You are reminded that giving false or misleading information is a serious offence under the Criminal Code.
Criterion 1 – Competence
1. Has the provider advised Comcare in writing of all individuals employed or engaged by the provider to manage return to work plans under the SRC Act, including evidence of qualifications and experience?
If no, provide an explanation and include the names of those individuals, attaching all relevant documentation.
Yes
Criterion 2: Probity
2. Has the provider, its principals or employees been refused approval as a provider of rehabilitation services or had such approval withdrawn under a workers' compensation scheme in any Australian State or Territory?
No
If yes, provide details of the circumstances and reasons why there is no cause to reject the provider’s application.
3. Have proceedings in relation to professional misconduct or criminal proceedings been taken (or are pending) against the provider, a principal or an employee?
No
If yes, provide details of the circumstances and reasons why there is no cause to reject the provider’s application.
4. During the immediately preceding six years, has the provider, its principals or employees, been subject to any award of damages, or settlement (with or without admission of liability) of any negligence claim, in respect of anything done or omitted in professional practice or training?
No
If yes, provide details of the circumstances and reasons why there is no cause to reject the provider’s application.
5. Has the provider or any principal been declared bankrupt in the last seven years?
No
If yes, provide details of the circumstances and reasons why there is no cause to reject the provider’s application.
6. Has the provider, a principal or an employee been found to have breached the Racial Discrimination Act 1975, the Sex Discrimination Act 1984, the Disability Discrimination Act 1992, the Privacy Act 1988 or equivalent State and Territory legislation?
No
If yes Provide details of the circumstances and reasons why there is no cause to reject the provider’s application.
7. Is the provider currently subject to the Commonwealth Privacy Act 1988?
No
Yes
Criterion 3: Financial requirements
8. The provider attests to its financial viability with a reference from an independent, qualified person (such as an accountant or bank manager).
No
If yes, attach reference
9. There is current coverage, which is sufficient to your level of risk, for:
(a) Professional indemnity insurance for all individuals employed and engaged by the provider to provide return to work services under the SRC Act
(b) Public liability insurance for the provider, and
(c) Workers’ compensation insurance where staff are employed by the provider.
No
Yes Provide a certificate of currency disclosing the name of the insured, the name of the insurance company, type of insurance/s, amount/s insured, policy number/s, amounts and duration of the coverage.
Criterion 4: Referral base
10. Has the provider had one or more referrals to provide services as a rehabilitation program provider under the Safety, Rehabilitation and Compensation Act 1988 in the past twelve months?
No Please attach explanation.
Yes □ Australian Government or ACT Public Sector
□ Licensed self-insurer (i.e. Telstra, Australia Post)
□ Other Commonwealth schemes (Seacare or Military Rehabilitation Compensation Commission)
Criterion 5: Satisfactory evaluation of performance
Outcome Standards
11. Upon receipt of this application Comcare will assess the provider’s performance against Comcare’s Outcome Standards (return to work rate, cost and duration) for the relevant period.
Where the provider anticipates that they may have failed to meet any of the outcome standards, the provider may attach a statement explaining the circumstances.
Service Standards – Self-assessment tool
12. Having reviewed the identified files, the provider confirms compliance with each standard by placing a tick in the relevant space in the table provided in Part Two. Comcare may ask the provider to produce documentation which confirms compliance.
Where the provider has not met the relevant service standard, a statement explaining the circumstances shall be attached to the application for Comcare’s consideration.
Service Standards – Capacity to meet standards in force from 1 July 2007, the renewal date
13. Describe the provider’s management of the return to work process to address how they would identify and seek to mitigate any personal, social or environmental risk factors which may be present in more complex cases. Also describe how in cases more than 12 weeks incapacity the provider’s approach to reduce the risk of ongoing chronicity, including how they would engage treating practitioners to resolve certified medical restrictions and incorporate evidence-based medical recovery timeframes.
**Where indicated – insert dates where requested otherwise insert a tick against each standard you have complied with.
| Self-assessment criteria | File 1 | File 2 | File 3 | File 4 | File 5 |
| Date of injury | | | | | |
| Date of referral to provider | | | | | |
| Date of return to work (in any capacity) | | | | | |
| Service Standard 1 – Service philosophy |
| 1.3 Conflict of Interest The provider ensured no conflict of interest occurred, specifically treatment and occupational rehabilitation services were not provided to the same individual. | | | | | |
| 1.4 Privacy For the purposes of the rehabilitation process, a personal information release authority was obtained and the employee was advised of their privacy rights. | | | | | |
| Service Standard 2 – Return to work management |
| 2.1 Timely acknowledgement |
| Date of contact with case manager to acknowledge receipt of referral for assessment. | | | | | |
| 2.2 Ensure contact is made with all key parties within three working days |
| Date of contact with employee. | | | | | |
| Date of initial contact with supervisor. | | | | | |
| Date of contact with medical practitioner. | | | | | |
| 2.3 Assessment services undertaken within 10 working days |
| Date of workplace visit. | | | | | |
| Date of completion of initial assessment report. | | | | | |
| Date referring authority advised of outcome of initial assessment. | | | | | |
| Initial assessment of the employee’s capability of undertaking a rehabilitation program was completed within ten working days of receipt of a referral for assessment | | | | | |
| The referring rehabilitation authority advised of the outcome of the initial assessment within ten working days of a referral for assessment | | | | | |
| Cost of initial rehabilitation assessment | | | | | |
| 2.4 Return to Work plan |
| As soon as possible after the assessment was completed, a return to work plan was developed, negotiated with and approved by the referring rehabilitation authority. | | | | | |
| Date of Return to Work Plan | | | | | |
| 2.5 Return to The return to work plan detailed the: |
| Goals | | | | | |
| Roles and responsibilities | | | | | |
| Nature of interventions | | | | | |
| Costs | | | | | |
| Expected duration of the plan | | | | | |
| 2.7 There was consultation with treating health professionals and other relevant medical providers to ensure the plan was consistent with medical advice. | | | | | |
| 2.8 The return to work plan: |
| Workplace based | | | | | |
| Included worksite program monitoring | | | | | |
| Included review meetings with key parties | | | | | |
| 2.12 Employee contacted prior to a decision to recommend that the return to work plan be closed. | | | | | |
| 2.13 Feedback sought from the referring rehabilitation authority regarding level of satisfaction with the outcome of the return to work plan and the nature of services provided. | | | | | |
| Service Standard 3 – Suitable and durable employment |
| 3.1 The provider approached the return to work in line with the Comcare return to work hierarchy. | | | | | |
| Service Standard 4 – Staffing |
| 4.1 The staff member or contractor managing the return to work plan meets the competency requirements of criterion 1. | | | | | |
| 4.2 The staff member or contractor managing the return to work plan has completed the Comcare training for approved rehabilitation providers or was enrolled in the next program. | | | | | |
| Service Standard 5 – Administrative/financial responsibilities |
| 5.2 The staff member or contractor managing the return to work plan was covered by professional indemnity insurance. | | | | | |
| 5.4 Invoices show service description, date of service, name of claimant/employee, name of employer, Comcare Approved Provider Number, Comcare claim number, Comcare service code, cost for each date of service. | | | | | |
| Service Standard 6 – Evidence of compliance with operational standards |
| 6.1 Documentation is on file demonstrating ongoing compliance with these standards. | | | | | |
Section 2 – Agreement and authorisation
I, _________________________________________________________________
(please print full name)
holding the position of: ______________________________________________ ,
(please print title)
on behalf of the provider: _____________________________________________
(please print name of provider)
1) certify that the information provided in this renewal application and in support of the renewal application is true and correct. I understand that giving false or misleading information is a serious offence under the Criminal Code
2) agree to advise Comcare as soon as possible of any changes to the information provided in this renewal application
3) authorise relevant persons to provide to Comcare personal information in relation to this renewal application and for the purposes of enabling Comcare to determine whether the provider, a relevant principal or employee of the provider is complying with the Operational Standards For Rehabilitation Program Providers determined under section 34E of the SRC Act. In particular, I understand that this authorises Comcare to seek confirmation of the qualifications, probity and financial standing of the provider, relevant principals and the provider’s employees and the effectiveness, availability and cost of the rehabilitation programs which were provided by the provider, and
If the provider’s approval as a rehabilitation program provider is renewed,
4) understand that failure to comply with the Operational Standards for Rehabilitation Program Providers determined under section 34E of the SRC Act or the Criteria for Approval or Renewal of Approval of Rehabilitation Program Providers determined under section 34D of the SRC Act may result in the revocation of approval under section 34Q of that Act
5) agree to advise Comcare in writing within one month of any changes in individuals employed or engaged by the provider to manage return to work plans under the SRC Act, including evidence of qualifications and experience, and
6) agree to Comcare listing details about the provider on Comcare’s website.
Signed ………………………………………… (Applicant)
Date …………………………………………
What does Comcare mean by “certified copy”?
Applicants for approval or renewal of approval as rehabilitation providers by Comcare are required to submit documentary evidence in support if their application.
In the case of some of this evidence Comcare requires either an original document (returnable) or a certified copy of that document to be submitted.
Certified copies (or originals) are required of the following classes of document:
· All certificates held by applicants or their employees which are evidence that the applicant/employee possesses a degree or graduate diploma as described in Criterion 1.2 (a)
· All documentation submitted as evidence that the applicant/employee is currently registered with a relevant registration authority as described in Criterion 1.2 (c)
· All documentation submitted as evidence that the applicant/employee is a full member of a professional association related to the qualification referred to in the previous paragraph, or that they are eligible to be a full member of that association as described in Criterion 1.2 (d)
· All documentation relating to insurance coverage as described in Criterion 3.1(b) (see note below).
The certification consists of an endorsement on the actual copy which states that an appropriate person has sighted the original document and believes the copy to be a true copy of that document. A list of appropriate persons is at page two of this document. The person making the endorsing statement must sign the actual copy being provided to Comcare. This signature cannot be photocopied. For clarity that the signature is original, Comcare would prefer that it be in blue ink.
Send all requests for information to:
Approved Rehabilitation Providers – approval and renewal
Comcare
PO Box 9905
Canberra ACT 2601
Persons who can certify a document to Comcare
1. Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public
2. Australian Consular Officer or Australian Diplomatic Officer within the meaning of the Consular Fees Act 1985
3. Bailiff
4. Bank, building society, credit union or finance company officer with 5 or more continuous years of service
5. Chiropractor
6. Civil marriage celebrant
7. Commissioner for Affidavits or for Declarations
8. Dentist
9. Fellow of the National Tax Accountants’ Association
10. Judge, magistrate, master, clerk, registrar or deputy registrar of a court, or chief executive officer of a Commonwealth court
11. Legal practitioner
12. Medical practitioner
13. Member of the Association of Taxation and Management Accountants, the Institute of Chartered Accountants in Australia, the Australian Society of Certified Practising Accountants or the National Institute of Accountants
14. Member of the Australian Defence Force who is:
a) an officer, or
b) a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with five or more years of continuous service, or
c) warrant officer within the meaning of that Act.
15. Member of the Institute of Corporate Managers, Secretaries and Administrators
16. Member of the Engineers Australia, other than at the grade of student
17. Member of a Commonwealth, State or Territory parliament, legislature or local government authority
18. Minister of religion registered under Division 1 of Part IV of the Marriage Act 1961
19. Notary Public
20. Nurse
21. Patent attorney
22. Permanent employee of a Commonwealth, State, Territory or local government authority with five or more years of continuous service
23. Permanent employee of the Australian Postal Corporation with five or more years of continuous service who is employed in an office supplying postal services to the public
24. Person before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is made
25. Pharmacist
26. Physiotherapist
27. Police officer
28. Psychologist
29. Senior Executive Service officer of the Commonwealth, or of a State or Territory, or of a Commonwealth, State or Territory authority
30. Sheriff or Sheriff’s officer
31. Teacher employed on a full time basis at a school or tertiary education institution
32. Veterinary surgeon
33. Justice of the Peace