COMMONWEALTH OF AUSTRALIA
Safety, Rehabilitation and Compensation Act 1988
SECTIONS 34C and 34S
APPROVED FORM FOR APPLICATION FOR INITIAL APPROVAL AS A REHABILITATION PROGRAM PROVIDER
Comcare, pursuant to paragraph 34C(1)(a) and subsection 34S(1) of the Safety, Rehabilitation and Compensation Act 1988, revokes the form approved by Notice 21 of 2003 on 8 October 2003 and published in the Gazette on 15 October 2003 and approves the following form as the approved form for the purposes of persons applying under section 34B for approval as a rehabilitation program provider with effect on and from 1 January 2007.
Dated 29 September 2006
The seal of Comcare was affixed
in the presence of:
Barbara Bennett
Chief Executive Officer
Application Form pages 1- 12 attached
Safety, Rehabilitation and Compensation Act 1988
Application FORM FOR initial 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 applicants seeking approval to become a rehabilitation program provider under section 34C of that Act.
INFORMATION ON COMPLETING THE APPLICATION
3. During the application process, Comcare will consult with the applicant and may at any time request further information.
4. Comcare will approve the applicant under section 34F of the SRC Act where Comcare is satisfied that the applicant meets the criteria and is likely to be able to comply with the operational standards. Comcare will inform the applicant in writing of its decision.
5. Where all relevant information is provided with the application Comcare will endeavour to make a decision on approval within 8 weeks from receipt of the application. However applicants should note that the SRC Act provides a maximum period of six months from date of receipt for Comcare to process the application.
6. Successful applicants will be approved until 30 June 2010. The approved provider will need to make an application for renewal of approval to continue to provide services under the SRC Act beyond this date.
7. If you wish to make an application to become an approved rehabilitation provider, complete the enclosed form, include the processing fee and return it to:
Approved Rehabilitation Provider Applications
Comcare
GPO Box 9905, Canberra ACT 2601
In this application:
“applicant” includes:
(a) a sole trader
(b) a partnership, and
(c) a company.
“principal” has the same meaning as that term is defined in section 34 of the Safety, Rehabilitation And Compensation Act 1988, namely:
(a) if the applicant is a partnership—any of the partners, and
(b) if the applicant is a company—any of the directors of the company and, if the person responsible for the day to day running of the company is not a director, also that person.
Applicant details
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Name of business |
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What is your Australian Business Number (ABN)? |
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Are you a sole trader? | Name of sole trader: |
Are you a partnership? | Names of all partners:
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Are you a company?
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Business address – street |
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Business address – postal (if different) |
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Business phone number |
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Fax number |
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Contact person for this application
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Where the applicant provides services in more than one state or territory please identify each state or territory, phone number, street and postal address. Please attach information if applicable.
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Section 2 – Meeting the criteria for approval
Please provide the following information and documentation to establish that the applicant meets the Criteria for Approval of Rehabilitation Program Providers determined by Comcare under section 34D of the Safety, Rehabilitation and Compensation Act 1988 (“SRC Act”).
(a) Where registration with a relevant registration authority is required to practice in that state or territory, provide a certified copy of current registration (see appendix 1). Where full registration has not been granted, please provide a brief explanation of the conditions attached to that registration.
OR
(b) Where registration is not required to practice in that state or territory, provide a certified copy of current full membership of the relevant professional association (see appendix 1) (or current probationary membership leading to full membership).
OR
(c) Where registration is not required and the applicant cannot provide evidence of current membership of a relevant professional organisation, provide certified copies of relevant qualifications and evidence to establish eligibility for full membership of the relevant professional association (see appendix 1).
2. Describe how the applicant will manage employees requiring supervised professional practice and employees with less than six months experience in occupational rehabilitation.
3. Provide the contact details of three referees who have been significant purchasers of the applicant’s occupational rehabilitation services and who can attest to the applicant’s provision of occupational rehabilitation services and the applicant’s professional integrity, honesty and due diligence.
4. Has any of the following, to the best of the applicant’s knowledge, been refused approval as a provider of rehabilitation services or had approval withdrawn under a workers’ compensation scheme in any Australian State or Territory? If so, provide details of the circumstances and reasons why there is no cause to reject the applicant’s application.
(a) The applicant
(b) Any of its principals, or
(c) Any of its employees.
5. To the best of the applicant’s knowledge, have any proceedings been taken (or are pending) against any of the following, in relation to professional misconduct or criminal proceedings? If so, provide details of the circumstances and reasons why there is no cause to reject the applicant’s application.
(a) The applicant
(b) Any of its principals, or
(c) Any of its employees.
6. To the best of the applicant’s knowledge, during the immediately preceding six years have any of the following 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? If so, provide details of the circumstances and reasons why there is no cause to reject the applicant’s application.
(a) The applicant
(b) Any of its principals, or
(c) Any of its employees.
7. To the best of the applicant’s knowledge, have any of the following been declared bankrupt in the last seven years? If so, provide details of the circumstances and reasons why there is no cause to reject the applicant’s application.
(a) The applicant, or
(b) Any of its principals.
8. To the best of the applicant’s knowledge, have any of the following 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? If so, provide details of the circumstances and reasons why there is no cause to reject the applicant’s application.
(a) The applicant
(b) Any of its principals, or
(c) Any of its employees.
9. Comcare requires that all Approved Rehabilitation Providers be subject to the Commonwealth’s Privacy Act 1988. Please indicate which of the following Privacy Act coverage provisions is applicable:
(a) The applicant is a Commonwealth agency as defined in section 6 of the Privacy Act 1988
(b) The applicant is an ‘organisation’ as defined in section 6C of the Privacy Act 1988 (e.g. a health service provider or the applicant has an annual turnover exceeding $3 million), or
(c) The applicant has opted into coverage under section 6EA of the
Privacy Act 1988.
Information on the Privacy Act can be obtained from The Office of the Privacy Commissioner at their website, www.privacy.gov.au or telephone 1300 363 992.
10. Provide a reference from an independent, qualified person, such as accountant or bank manager, to attest to the financial viability of the applicant.
11. Provide a certificate of currency, disclosing the name of the insured, the name of the insurance company, type of insurance, amount insured for, policy number and end date of coverage for current:
(a) professional indemnity insurance for all individuals employed and engaged by the applicant to provide return to work services under the SRC Act, and
(b) public liability insurance for the applicant, and
(c) workers’ compensation insurance where staff are employed.
Section 3: Ability to meet operational standards
Please provide the following information and documentation to demonstrate the applicant’s ability to achieve and maintain the service standards for rehabilitation program providers determined under section 34E of the SRC Act.
12. Provide a brief description of the applicant’s service philosophy based on the key principles of occupational rehabilitation.
13. List the range of services offered by the applicant. Identify those services which would be offered under a return to work assessment or rehabilitation plan under the SRC Act.
14. Provide details of other jurisdictions where the applicant is currently accredited or approved as a rehabilitation program provider.
15. Describe how the applicant would manage its services so as to avoid any conflicts of interest.
16. Explain any training and procedures which are in place to ensure that the applicant and its staff abide by the Commonwealth’s Privacy Act 1988.
17. Describe the applicant’s management of the return to work process, addressing each element of Service Standard 2 and in particular describe how the provider would identify, then seek to mitigate any personal, social or environmental risk factors in more complex cases. For cases which approach 12 weeks of incapacity, please also describe the provider’s approach to reduce the risk of ongoing chronicity, in particular the provider’s approach with treating medical practitioners or therapists to resolve certified medical restrictions or programs of treatment against evidence based medical principles.
18. Describe how the applicant’s services are made accessible to persons of diverse cultural and social backgrounds.
19. Describe how the applicant would focus the treating doctor on the ability rather than the disability of the injured employee.
20. Describe how the applicant will meet Service Standard 3.
21. Describe how the applicant will meet Service Standard 4.
22. Outline the applicant’s charging rates.
23. Provide an example of the applicant’s invoice and invoicing cycle.
24. Describe how the applicant will track and bill services provided under the SRC Act.
25. Describe the applicant’s record keeping system including storage and security.
26. Describe how the applicant will document evidence on file to demonstrate ongoing compliance with these standards.
I, _________________________________________________________________
(please print full name)
holding the position of: _______________________________________________ ,
(please print title)
on behalf of the applicant: _____________________________________________
(please print name of applicant)
1) certify that the information provided in this application and in support of the 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 application, and
3) authorise relevant persons to provide to Comcare personal information in relation to this application and for the purposes of enabling Comcare to determine whether the applicant, a relevant principal or employee of the applicant 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 applicant, relevant principals and the applicant’s employees and the likely effectiveness, availability and cost of the rehabilitation programs which may be provided by the applicant.
If the applicant is approved as a rehabilitation program provider, I:
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 Rehabilitation Program Providers determined under section 34D of the SRC Act may result in the revocation of approval under section 34Q of that Act; and
5) agree to advise Comcare in writing within one month of any changes in individuals employed or engaged by the applicant to manage return to work plans under the SRC Act, including evidence of qualifications and experience; and
6) agree to Comcare listing the applicant’s name, service delivery description and contact details 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:
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.
The address to which additional documentation requested by Comcare should be sent is:
Approved Rehabilitation Provider – applications and renewals
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