Motor Accident Medical Report
This form is Approved Form AF2014-58, approved on 26 August 2014 by Karen Doran, delegate of the director-general, 
under section 276 of the Road Transport (Third-Party Insurance) Act 2008. 
As prescribed by section 84 (2)(d) of the Road Transport (Third-Party Insurance) Act 2008.

Part A: Patient's information

Title	Mr	Mrs	Ms	Miss	Dr Other
Full Name Street Address
Date of Birth	Medicare number

Date of Accident

Part B: Medical Information (To be completed by your doctor)

Date of examination	Are the injuries consistent with the circumstances of the motor accident described to you?

Yes	No

Medical diagnosis or description of injury

Clinical findings (Symptoms, results of any investigations)

How long has the patient attended the practice?

Has the patient been treated for a similar condition or had an injury to the same area in the past?

Yes	No

If yes, give details?

Did the patient require an ambulance?

Yes	No	Did the patient attend hospital?

Yes	No

Was the patient admitted to hospital?

Yes	No	Name of Hospital
(if patient attended or was admitted)?

Is treatment likely to be required

Short term (6 weeks)	Medium term (6-12 weeks)
Long term (>12 weeks)	No treatment necessary

Treatment type	GP Management	Allied Health Therapy
Specialist	Other

Detail of treatment (including detail of treatment/ rehabilitation already undertaken)

Name of Provider	Contact Number

Patient's fitness for work

Unfit for work from:	until:	Date of next review:

Fit to resume normal duties with restrictions on:

Restrictions

Fit to resume normal duties on:

Medical Practitioner's information

Doctor's name	Work phone number

Area of specialty Provider number Address of practice

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 of medical practitioner

Date

Protection of Privacy
•	The information collected by this Motor Accident Medical Report, and throughout the course of your claim, is collected in accordance with the Road Transport (Third-Party Insurance) Act 2008 (the Act) and Road Transport (Third-Party Insurance) Regulation 2008 (the Regulation).
•	The information is collected so as to encourage the speedy resolution of personal injury claims resulting from motor vehicle accidents, and to help the administration of the statutory insurance scheme and the detection of fraud.
•	The information collected by this Motor Accident Medical Report and throughout the course of your claim, may be disclosed in accordance with the Act and the Regulation to such bodies as, the CTP regulator, the Nominal Defendant, and other insurers or parties involved in the assessment of your claim, such as those indicated below.
•	Failure to provide all or part of the information may delay or prevent the assessment of your claim.
•	You are able to gain access to personal information held as provided by the Privacy Act 1988 (Cth), or if the information is held by the Australian Capital Territory Government, you are able to gain access to the information as provided by the road transport legislation.
•	Any personal information you provide to the CTP Insurer will be collected, held, used and disclosed in accordance with their Privacy Policy. You will be able to view their privacy policy on their website or you can request that the Insurer send you a copy.