Gym and pool membership request and evaluation form

Instructions

This form should be completed by a registered medical practitioner, physiotherapist, osteopath, chiropractor or accredited exercise physiologist when requesting a gym and/or pool membership for a TAC client.

To request a subsequent membership, supervising health professionals are expected to report on client progress using valid outcome measures on this form. The TAC will use this information to consider if the membership continues to be reasonable, clinically justified and outcome focused.

More information is available in the Gym and pool memberships section of our Allied Health policy.

To avoid delays, complete in full and attach copies of any additional relevant information including a quote from the Gymnasium or Swimming pool/Aquatic facility that meets the TAC's invoice requirements.

TAC client details

First name *

Last name *

Claim number *

Date of birth *

Date of accident *

Membership details

Type of request *

InitialSubsequent

A subsequent membership will be considered if there has been demonstrable functional improvement with a previous membership, and further functional improvement is expected with a subsequent membership.

Type of membership *

GymPoolBoth gym and pool

The TAC can consider approving memberships that run for up to 3 months. Please ensure the dates you enter below are for a 3 month period or less.

Membership: date from *

Membership: date to *

Please upload a quote from the gym/pool

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Original goals of membership and subsequent progress

Goals of membership

Goal *

Please comment on progress *

Please comment on current status *

Functional changes and outcome measures

Please refer to the Outcome measures page on our website for more information

Current functional activities and baseline outcome measures

Please refer to the Outcome measures page on our website for more information

Outcome measure / Functional activity *

Date of assessment *

Assessment score *

Rehabilitation/maintenance

What self-management strategies are currently being undertaken by the client? *

What are the rehabilitation goals of the subsequent membership? *

How are these rehabilitation goals are aligned to the client’s independence goals? *

Treating practitioner details

First name *

Last name *

Treating practitioner's address *

Street name and number *

City *

State *

Postcode *

Phone number *

Email *

Days/hours available

Signature *

Draw signature|Type signatureClear

Date *

Privacy

The TAC will retain the information provided and may use or disclose it to make further inquiries to assist in the ongoing management of the claim or any claim for common law damages. The TAC may also be required by law to disclose this information. Without this information, the TAC may be unable to determine entitlements or assess whether the treatment is reasonable and may not be able to approve further benefits and treatment.

If you require further information about our privacy policy, please call the TAC on 1300 654 329 or visit our website at tac.vic.gov.au/privacy