Three month gym/swim membership request

Use this form to apply for payment of your gym or swim membership as part of your workcover claim.

Shape
 
Published: 24 Jun 2020
 
File type: PDF
 
File size: 74.88 kB
 
Length: 2 pages
 
Reading level: Easy

What it contains

This form should be filled in by your referring health practitioner and submitted to your WorkSafe agent.