JME supplementary report request form

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Solicitors must use this form to request a Joint Medical Examination (JME) on behalf of a client and the TAC under Part 3 of the Transport Accident Act 1986 (TAA) and pursuant to the JME Protocols 2016.

Client details

Client first name *

Client last name *

Date of birth *

Date of accident *

TAC claim number for supplementary report request *

Does the client have any other TAC claims? *

YesNoNot known

TAC claim number *

Is this claim related to the supplementary report request? *

YesNo

Client's lawyer

Firm name *

Law firm address *

Street address *

City *

State *

Postcode *

Practitioner *

Reference number

Phone number *

Email address *We will email a copy of your application to this email address.

Request type

Please select the request type *

Addendum report (no additional supporting information to be provided)Supplementary report (further information to be provided)

Documentation to attach with request

Please provide the following list of documents in order for this request to be approved:

Copy of addendum report request *

Browse

Copy of supplementary report request *

Browse

Additional information to be provided to examiner (if required)

Browse

Reason reports required

Please provide brief reasons as to why this supplementary report/addendum is required *For example, how it will alter the impairment score, confirm diagnosis, prognosis, etc.

Who are the reports required from?

Examiner's full name *

Examiner's discipline *

Examiner's email address *

Other comments

Other comments that would assist the TAC in reviewing your request for approval of the additional report request.

Classification

Internal TAC reference, please ignore

Information for solicitors

The form is completed on a without prejudice basis to promote the efficient administration of the Protocols and cannot be relied upon in any later Court or Tribunal proceedings (unless otherwise agreed).

The TAC’s privacy policy

The TAC respects the privacy of clients. The TAC will retain any information provided to the TAC as part of the JME process, and may use or disclose that information to make further inquiries or assist in the ongoing management of the client’s TAC claim. The TAC may also be required by law to disclose any information provided to the TAC.

If you require further information about the TAC’s Privacy Policy, please call the TAC on 1300 654 329 or visit our website at tac.vic.gov.au/yourprivacy