Customer details:
Job Seeker Identification (JSID) Number:Customer Name:
DOB: / Male/Female:
Customer Address:
Phone Number:
Mobile Number:
Email Address:
Referring Provider Details:
JCA Provider Name: Work Solutions (HSA) / Assessor Name:Postal Address:
State/Territory: / Postcode:
Telephone No.: / Fax No.:
Business Email Address:
Job Capacity Account Service Provider Details:
Job Capacity Account Service Provider:Address:
Name of Contact:
Service Type Requested: / - Please Select ------Psychological SupportPhysical SupportSocial Support Subcategory (if known): - Please select ------CBTBehaviour ModificationOther Psychological SupportSocial Case Work and SupportOther Social SupportCounselingWork ConditioningPain ManagementOther Physical Support
If ‘Other’ service has been selected, please specify:
Session fee*
Up to 90 mins for initial and final & 60 mins for subsequent. Up to $170 per hour (Reg Psych) or $155 (Allied Health Prof)
*Prices may only differ if durationof session differs / DNA Fee*
DNA $ 110 (Max 2)
*DNA fees must not exceed $110 (incl GST) / Exit Report Fee*
$ 150
*Exit report fee must not exceed $150 (incl GST) / Total Service Fee*
Up to $1560 (Reg Psych) or
$1455 (Allied Health Prof)
*Total cost of service is based on 6 sessions, exit report andother claimable items and must not exceed an average of $1,000(excl GST) per customer. Price may differ if interpreter was required max $83 per session or travel, ATO KM rate.
GST inclusive GST exclusive
Accept Referral Decline Referral
TO BE COMPLETED BY JOB CAPACITY ACCOUNT SERVICE PROVIDER:
- I acknowledge receipt of referral and agree to the terms stated in the referral form including set fees, number of sessions approved and service requirements;
- I understand that failure to return this confirmation of service may result in non-payment of invoices;and
- Iagree to the terms and conditions in the Job Capacity Account Guidelines.
Customer Name: JSID:
Details of first scheduled appointment:
Signature:______PrintedName:
Date://
Please return confirmation to referring Job Capacity Assessment provider
Service Requirements:Interpreter required: / Yes NoIf yes, please specify language
Number of sessions approved: / Six Other.
If Other, please specify
Date of submission:
(date the JCA Report was submitted)
Date sessions required to commence by:
(within 4 weeks of JCA report being submitted) / Date sessions must be completed by:
(within 16 weeks of JCA report being submitted)
Barriers identified through the JCA that this service is to address:
Expected outcomes of the Job Capacity Account service:
Other service requirements / details:
Current Job Services Australia Provider Information:
Job Services Australia Provider:
Postal Address:
Phone:
Email:
Option for forwarding the Job Capacity Account Exit Report:
Preferred Process:Email
Contact Name: JCAc National Billing
Postal Address:PO Box 12499, A’Beckett Street, VIC 8006
Phone: 03 9224 8800
Email:
Please ensure that a copy of the Exit Report is forwarded to the Customer at the address requested by customer
Option for forwarding Job Capacity Account Invoices:
Preferred Process: Email
Contact Name: JCAc National Billing
Postal Address: PO Box 12499, A’Beckett Street, VIC 8006
Phone: 03 9224 8800
Email:
Job Capacity Account External Referral Form July 09 Draft 26 8 09– June 2009 Page 1 of 2