Appendix 5- Comcare Agreement and Authorisation

I, _________________________________________________________________

(please print full name)

holding the position of: ______________________________________________,

(please print title)

on behalf of the provider: _____________________________________________

(please print name of provider)

1. certify that the information provided in this renewal application and in support of the renewal application is true and correct. I understand that giving false or misleading information is a serious offence under the Criminal Code

2. agree to advise Comcare as soon as possible of any changes to the information provided in this renewal application

3. authorise relevant persons to provide to Comcare personal information in relation to this renewal application and for the purposes of enabling Comcare to determine whether the provider, a relevant principal or employee of the provider is complying with the Operational standards for rehabilitation program providers (workplace rehabilitation providers) determined under section 34E of the SRC Act. In particular, I understand that this authorises Comcare to seek confirmation of the qualifications, probity and financial standing of the provider, relevant principals and the provider’s employees and the effectiveness, availability and cost of the rehabilitation programs which were provided by the provider, and

If the provider’s approval as a workplace rehabilitation provider is renewed,

4. understand that failure to comply with the Operational standards for rehabilitation program providers (workplace rehabilitation providers) determined under section 34E of the SRC Act or the Criteria for initial approval or renewal of approval of rehabilitation program providers (workplace rehabilitation providers) determined under section 34D of the SRC Act may result in the revocation of approval under section 34Q of that Act

5. agree to advise Comcare in writing within one month of any changes in individuals employed or engaged by the provider to manage return to work plans under the SRC Act, including evidence of qualifications and experience, and

6. agree to Comcare listing details about the provider on Comcare’s website.

Signed ………………………………………… (Applicant)

Date …………………………………………

.