Medical Certificate
For Compulsory Third Party (CTP) Insurance Claims
to be completed by a Medical Practitioner
For information on the ACT Compulsory Third Party Scheme phone NRMA Insurance on (02) 6240.4700
Claimant’s Information	

Claimant’s Surname/Family Name	    	      Given Names				     Date of Birth

				
            /                 /	

Medical Information	

Date of Accident                   Date of Initial Examination					   

      /               /		
           /                /	Are the injuries/conditions consistent with the circumstances of the motor accident described to you?	
  Yes		  No	

Description of Injury / Diagnosis

	

	

Clinical Findings (symptoms, results of any investigations and details of treatment/rehabilitation to date)

	

	

How long have you known this patient?              			Has the patient had a similar condition?

		

							
Did the patient require an ambulance?        Did the patient attend hospital?        If admitted to hospital, was it more than 1 day?

  Yes		  No
		
  Yes		  No		
  Yes		  No	

Name of Hospital					              	        Date of first attendance at hospital

                /                      /	

Will further treatment or therapy be required?			      Date patient was discharged from hospital

  Yes		  No		
               /                      /	

Details of Treatment, Medication and / or Therapy Necessary or Likely

	

	

	

	

Referred to:		Type			Name of Person		Phone Number or Contact Details
  Specialist	

  Therapist	

  Other	

Describe the patient’s fitness for work							 Date of Next Medical Review
  Fit to resume normal duties           Date:         /           /	

                /              /	

  Certified fit for alternative duties.   Date from:            /            /            to             /           /	

  Certified unfit for work.                   Date from:          /              /            to           /             /	

Medical Practitioner’s Information	

Name (please print)					  	Provider Number

	

                                 /	

Practice Name and Address/Hospital Name

	

Telephone Number	   	      Professional Qualification

	

	

I declare that I am a registered medical practitioner and to the best of my knowledge the information provided here is true and correct.

Signature								Date

	

         /            /