JME request form

JME REQUEST FORM: JME PROTOCOLS

Important notes:

This form is to be used by lawyers requesting 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.

Please consider whether bypassing the impairment assessment process in accordance with the Supplementary Common Law Protocols would better serve the client's interests, particularly in fast-tracking their serious injury application or common law claim. For example, the client has a clear serious injury and you have information that indicates another party is at fault.

Please complete this form identifying the JME(s) and provide any information and documents in support of your request.

Purpose of examination(s) *

Client details

Client first name *

Client last name *

Date of birth *

Date of accident *

Client email

My client consents to receive an email that outlines the impairment process and includes a link to the TAC's impairment benefits brochure on the TAC website.

Please note, we will also send you a copy of this email.

Claim number *

Client age

Is client under 18 years of age

Does the client have any other TAC claims? *

YesNoNot known

TAC claim number *

Is this claim related to the JME request? *

YesNo

Please ensure you provide the examiner/s medical information related to these claims.

Client's lawyer

Firm name *

Firm's address *

Street name and number *

City *

State *

Postcode *

Practitioner *

Reference number *

Phone number *

Fax number

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

Request type

Please select the request type *

Existing solicitor arranged – Examination to be converted to JME(s)Joint TAC arranged – Examination to be converted to JME(s)

Appointment details

Exam 1

Appointment date and time *

The number of days exam 1 is after the accident

Number of days exam 1 is from today

As this examination request is within 12 months of the date of accident, the TAC requires supporting evidence to show that the client’s injuries are considered stable for an examination.

Please note: This exam is within 28 days. You must contact the TAC for pre-approval for any exams within 28 days of the request date.

Please upload evidence to support that the client's injuries are stable *

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Examiner's full name *

Examiner's discipline *

Examiner's address *

Street name and number *

City *

State *

Postcode *

Examiner's email address *

Examiner's phone number *

Was this appointment booked through a Medico-legal provider? *

YesNo

Name of Medico-legal provider *

Medico-legal provider's email address *

Add another appointment? *

YesNo

Exam 2

Appointment date and time *

The number of days exam 2 is after the accident

Number of days exam 2 is from today

As this examination request is within 12 months of the date of accident, the TAC requires supporting evidence to show that the client’s injuries are considered stable for an examination.

Please note: This exam is within 28 days. You must contact the TAC for pre-approval for any exams within 28 days of the request date.

Use the same evidence as previously uploaded.

Please upload evidence to support that the client's injuries are stable *

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Examiner's full name *

Examiner's discipline *

Examiner's address *

Street name and number *

City *

State *

Postcode *

Examiner's email address *

Examiner's phone number *

Was this appointment booked through a Medico-legal provider? *

YesNo

Name of Medico-legal provider *

Medico-legal provider's email address *

Add another appointment? *

YesNo

Exam 3

Appointment date and time *

The number of days exam 3 is after the accident

Number of days exam 3 is from today

As this examination request is within 12 months of the date of accident, the TAC requires supporting evidence to show that the client’s injuries are considered stable for an examination.

Please note: This exam is within 28 days. You must contact the TAC for pre-approval for any exams within 28 days of the request date.

Use the same evidence as previously uploaded.

Please upload evidence to support that the client's injuries are stable *

Browse

Examiner's full name *

Examiner's discipline *

Examiner's address *

Street name and number *

City *

State *

Postcode *

Examiner's email address *

Examiner's phone number *

Was this appointment booked through a Medico-legal provider? *

YesNo

Name of Medico-legal provider *

Medico-legal provider's email address *

Add another appointment? *

YesNo

Exam 4

Appointment date and time *

The number of days exam 4 is after the accident

Number of days exam 4 is from today

As this examination request is within 12 months of the date of accident, the TAC requires supporting evidence to show that the client’s injuries are considered stable for an examination.

Please note: This exam is within 28 days. You must contact the TAC for pre-approval for any exams within 28 days of the request date.

Use the same evidence as previously uploaded.

Please upload evidence to support that the client's injuries are stable *

Browse

Examiner's full name *

Examiner's discipline *

Examiner's address *

Street name and number *

City *

State *

Postcode *

Examiner's email address *

Examiner's phone number *

Was this appointment booked through a Medico-legal provider? *

YesNo

Name of Medico-legal provider *

Medico-legal provider's email address *

Add another appointment? *

YesNo

Exam 5

Appointment date and time *

The number of days exam 5 is after the accident

Number of days exam 5 is from today

As this examination request is within 12 months of the date of accident, the TAC requires supporting evidence to show that the client’s injuries are considered stable for an examination.

Please note: This exam is within 28 days. You must contact the TAC for pre-approval for any exams within 28 days of the request date.

Use the same evidence as previously uploaded.

Please upload evidence to support that the client's injuries are stable *

Browse

Examiner's full name *

Examiner's discipline *

Examiner's address *

Street name and number *

City *

State *

Postcode *

Examiner's email address *

Examiner's phone number *

Was this appointment booked through a Medico-legal provider? *

YesNo

Name of Medico-legal provider *

Medico-legal provider's email address *

Add another appointment? *

YesNo

Exam 6

Appointment date and time *

The number of days exam 6 is after the accident

Number of days exam 6 is from today

As this examination request is within 12 months of the date of accident, the TAC requires supporting evidence to show that the client's injuries are considered stable for an examination.

Please note: This exam is within 28 days. You must contact the TAC for pre-approval for any exams within 28 days of the request date.

Use the same evidence as previously uploaded.

Please upload evidence to support that the client's injuries are stable *

Browse

Examiner's full name *

Examiner's discipline *

Examiner's address *

Street name and number *

City *

State *

Postcode *

Examiner's email address *

Examiner's phone number *

Was this appointment booked through a Medico-legal provider? *

YesNo

Name of Medico-legal provider *

Medico-legal provider's email address *

Add another appointment? *

YesNo

Exam 7

Appointment date and time *

The number of days exam 7 is after the accident

Number of days exam 7 is from today

As this examination request is within 12 months of the date of accident, the TAC requires supporting evidence to show that the client’s injuries are considered stable for an examination.

Please note: This exam is within 28 days. You must contact the TAC for pre-approval for any exams within 28 days of the request date.

Use the same evidence as previously uploaded.

Please upload evidence to support that the client's injuries are stable *

Browse

Examiner's full name *

Examiner's discipline *

Examiner's address *

Street name and number *

City *

State *

Postcode *

Examiner's email address *

Examiner's phone number *

Was this appointment booked through a Medico-legal provider? *

YesNo

Name of Medico-legal provider *

Medico-legal provider's email address *

Add another appointment? *

YesNo

Exam 8

Appointment date and time *

The number of days exam 8 is after the accident

Number of days exam 8 is from today

As this examination request is within 12 months of the date of accident, the TAC requires supporting evidence to show that the client’s injuries are considered stable for an examination.

Please note: This exam is within 28 days. You must contact the TAC for pre-approval for any exams within 28 days of the request date.

Use the same evidence as previously uploaded.

Please upload evidence to support that the client's injuries are stable *

Browse

Examiner's full name *

Examiner's discipline *

Examiner's address *

Street name and number *

City *

State *

Postcode *

Examiner's email address *

Examiner's phone number *

Was this appointment booked through a Medico-legal provider? *

YesNo

Name of Medico-legal provider *

Medico-legal provider's email address *

Add another appointment? *

YesNo

Exam 9

Appointment date and time *

The number of days exam 9 is after the accident

Number of days exam 9 is from today

As this examination request is within 12 months of the date of accident, the TAC requires supporting evidence to show that the client’s injuries are considered stable for an examination.

Please note: This exam is within 28 days. You must contact the TAC for pre-approval for any exams within 28 days of the request date.

Use the same evidence as previously uploaded.

Please upload evidence to support that the client's injuries are stable *

Browse

Examiner's full name *

Examiner's discipline *

Examiner's address *

Street name and number *

City *

State *

Postcode *

Examiner's email address *

Examiner's phone number *

Was this appointment booked through a Medico-legal provider? *

YesNo

Name of Medico-legal provider *

Medico-legal provider's email address *

Add another appointment? *

YesNo

Exam 10

Appointment date and time *

The number of days exam 10 is after the accident

Number of days exam 10 is from today

As this examination request is within 12 months of the date of accident, the TAC requires supporting evidence to show that the client’s injuries are considered stable for an examination.

Please note: This exam is within 28 days. You must contact the TAC for pre-approval for any exams within 28 days of the request date.

Use the same evidence as previously uploaded.

Please upload evidence to support that the client's injuries are stable *

Browse

Examiner's full name *

Examiner's discipline *

Examiner's address *

Street name and number *

City *

State *

Postcode *

Examiner's email address *

Examiner's phone number *

Was this appointment booked through a Medico-legal provider? *

YesNo

Name of Medico-legal provider *

Medico-legal provider's email address *

The maximum number of appointments available on this form is 10. Please complete a new JME request form if you require additional appointments.

Additional appointment needs

Security booked - Solicitor to arrange and must discuss risk with the examiner when securing the appointment.

For which exams have you booked security? *Add the exam numbers with security booked, or type 'All' to indicate all exams.

Interpreter needed/booked - Solicitor to arrange and advise the examiner

For which exams have you booked an interpreter? *Add the exam numbers with an interpreter booked, or type 'All' to indicate all exams.

Telehealth - Solicitor to confirm with the client telehealth video conference details.

Which exams are telehealth? *Add the exam numbers for telehealth, or type 'All' to indicate all exams.

I confirm that I have considered these appointments to be suitable for telehealth. *

Special requirements

Please detail the client's other special requirements *

Which exams have these special requirements? *Add the exam numbers for any exams with special requirements, or type 'All' to indicate all exams.

Travel and accommodation needs

Taxi required – The TAC to arrangeTravel required – The TAC to arrangeAccommodation required – The TAC to arrange

Note: it is preferable for the client to find their own way to the examinations. However if your client is unable to use their pre-accident mode of transport because of their transport accident injuries, taxi travel may be reasonable

Taxi required questions

Please choose taxi type *

Regular taxiMaxi taxi

Note: Consider if your client needs scooter or wheelchair accessibility.

Reason taxi required *

Which exams require a taxi? *Add the exam numbers that require a taxi, or type 'All' to indicate all exams.

Travel required questions

Does your client need assistance to travel? *

YesNo

Please provide medical documentation specifically confirming the need for assistance. *

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Please complete the carer's details below. The TAC needs these details to secure tickets with external providers (booking flights etc.)

Carer's first name *

Carer's last name *

Carer's date of birth *

What airport is most convenient for your client to travel in and out of?

Travel from airport *

Travel to airport *

What are the approximate departure and arrival dates and times required?

Departure date and time *

Arrival date and time *

If there are any other travel requirements that the TAC needs to be aware of, please add them below

Which exam(s) have these travel requirements? *Add the exam numbers that require travel, or type 'All' to indicate all exams.

Do you need to add different travel requirements for other exams? *

YesNo

Travel from airport

Travel to airport

Departure date and time

Arrival date and time

Carer details and special requirements for additional travel *If you need the same carer and requirements as listed above, please indicate 'Same as above'. If you have different carer's or requirements for the additional travel, please provide all details here, including the carer's full name and date of birth.

Accommodation required questions

Is your client travelling with a carer? *

YesNo

Carer's first name *

Carer's last name *

Are separate bedrooms required *

YesNo

Are separate beds required? *

YesNo

What are the preferred check in and check out dates?

Check in date

Check out date

If there are any other accommodation requirements that the TAC needs to be aware of, please add them below

Which exams require accommodation? *Add the exam numbers that require accommodation, or type 'All' to indicate all exams.

Do you need to add different accommodation requirements for other exams? *

YesNo

Check in date

Check out date

Separate bedrooms?

YesNo

Separate beds?

YesNo

Carer details and special requirements for additional accommodation *If you need the same carer and requirements as listed above, please indicate 'Same as above'. If you have different carer's or requirements for the additional travel, please provide all details here, including the carer's full name and date of birth.

Client's injuries

Please list an injury and the TAC claim it relates to.

One injury per line.

Injury *

TAC claim number for this injury *

Supporting documentation

Where appropriate, please provide the following list of documents relied upon in the request and attach copies where not previously provided to the TAC.

Check an option to upload your supporting documents.

Letter of instruction

Letter of instruction upload

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Treating practitioner reports and material

Treating practitioner reports and material upload

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List of your treating practitioner reports

{{treating practitioner reports and material upload}}

Medico-Legal report

Medico-Legal report upload

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List of your medico-legal reports

{{medicolegal report upload}}

Other

Please provide a brief description of the type of documents *

Other comments

Other comments that would assist the TAC in reviewing your JME request

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

Internal TAC document reference, please ignore

Internal TAC reference, please ignore

Information about using the 'Save and complete later' feature

You must not attach documents to this form until you are ready to submit.

Any attachments uploaded and saved without submitting are added at the user's risk, and the security of the information saved cannot be guaranteed by the TAC until the form is submitted.

Save and Complete Later