JME reschedule application

JME RESCHEDULE APPLICATION: JME PROTOCOLS

Important notes:

This form is to be used by lawyers rescheduling an approved Joint Medical Examination (JME) on behalf of a client and the TAC made under Part 3 of the Transport Accident Act 1986 (TAA) and pursuant to the JME process as detailed in the JME Protocols 2016.

This form should not be used when cancelling an appointment. Upon receipt of this form, the TAC will cancel the original JME appointment.

Purpose of examination(s) *

Client details

Client first name *

Client last name *

Date of birth *

Date of accident *

Claim number *

Client's lawyer

Firm name *

Firm address *

Street address *

City *

State *

Postcode *

Practitioner *

Reference number *

Phone number *

Fax number

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

Appointment details

Reschedule type (of an existing JME appointment) *

To a new dateWith a different examiner (of the same discipline / specialty)

Reschedule reason *

Original JME to be cancelled

Appointment date and time *

Examiner's full name *

Examiner's discipline *

New JME details

New appointment date and time *

Number of days new appointment is after today

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.

Examiner's full name *

Examiner's discipline *

Examiner's address *

Street address *

City *

State *

Postcode *

Is this the examiner's postal address? *

YesNo

Examiner's postal adress *

Postal address *

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 *

Additional needs

Security booked – Solicitor to arrange and must discuss risk with the examiner at time of securing the appointmentInterpreter needed/booked – Solicitor to arrange and advise examinerTelehealth - Solicitor to confirm with client telehealth video conference detailsSpecial requirements

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

Please detail the client's other special requirements *

Travel and accommodation needs

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

Taxi required questions

Please choose taxi type *

Regular taxiMaxi taxi

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

Reason taxi required *

Travel required questions

Does your client need assistance to travel? *

YesNo

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

Browse

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

Carer's full 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 *

Are there any other special requirements that the TAC needs to be aware of, not captured above?

Accommodation required questions

Is your client travelling with a carer? *

YesNo

Carer's full 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

Are there any other special requirements that the TAC needs to be aware of, not captured above?

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 client. 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 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

Classification

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