Information for General Practitioners FACT SHEET No.5

Medical records, reports and certificates

Executive summary

Medical practitioners should be aware that medical notes and letters to health practitioners about an employee’s condition may, in the case of workers’ compensation claims, be released to third parties in certain circumstances. A number of stakeholders such as the case manager, claims manager or rehabilitation provider may contact the general practitioner for information to enable them to do their jobs properly. The treating doctor should be able to provide the necessary advice where written consent from the injured employee has been provided.

Notes

Notes made by a medical practitioner are normally only intended for the use of the medical practitioner as an aide-memoir and may contain confidential and sensitive information that the doctor may not intend for further dissemination. However, medical practitioners need to be aware that in workers’ compensation cases clinical notes may be produced in either the Administrative Appeals Tribunal (AAT) or the courts, sometimes years after the notes were made.

Letters to other health practitioners

Letters from medical practitioners to other health service providers need to be honestly but carefully expressed in terms that will not affect the doctor/patient relationship if the patient becomes aware of the contents. While the author of the letter should be provided with a request for permission before the contents of a letter are disclosed, his or her veto may not be enough to prevent the subsequent disclosure to other parties, including the employee.

Requests for information

There are a number of stakeholders who may request additional information from the treating doctor to enable them to undertake their roles properly. These stakeholders can include the case manager, the claims manager and the rehabilitation provider. For further information see Fact Sheet No. 3 — The treating doctor’s interactions with other stakeholders. Before providing information, the treating doctor needs to be sure that the injured employee has provided written consent to the release of information. Requests from the claims manager should provide a photocopy of the compensation claim form, signed and dated by the employee and containing the employee’s consent to the release of medical information. Where a review of an ongoing claim is necessary, it may be appropriate for the claims manager to obtain a new consent to the release of medical information. A treating doctor may request that an original consent form be obtained before releasing any medical information. In making this decision, the doctor needs to be aware that obtaining a new written consent may delay a decision on the acceptance of a claim until the claims manager can get the necessary information. The way in which information from doctors may be requested may depend on the purpose for which the information will be used. For example, a claims manager who may be making a formal written determination on whether or not to accept liability for a claim will usually require a written report. However, a case manager or rehabilitation provider who wishes to discuss a proposed return to work plan or clarify medical restrictions provided on a certificate may be able to achieve this through a phone call.

Medical Certificates

A medical certificate must be included with an employee’s Claim for Workers’ Compensation Form. Claims for workers’ compensation that are not supported by medical evidence can not be accepted. While Comcare has developed a medical certificate form to assist employees in lodging a claim (Comcare Medical Certificate), it is not mandatory to use this form. Treating doctors can use their own certificates but the acceptance of a claim for compensation may be delayed if all the necessary information is not available. For more information on what information must be in the medical certificate, see Fact Sheet No. 2 — The treating doctor and workers’ compensation under the Safety, Rehabilitation and Compensation Act 1988 (the SRC Act).

Page last updated:August 18, 2008