Respondent must provide information to Medical Panel
9 Respondent must provide information to Medical Panel
For the purposes of section 28LZA(1)(a)(ii) of the Wrongs Act 1958, the following information is prescribed—
the name of the respondent;
the address of the respondent;
the telephone number of the respondent;
the email address of the respondent;
the date on which the respondent received the claimant's certificate of assessment;
the name, address, telephone number and email address of the respondent's legal or other representative (if any);
the claimant's statement of claim (if this has been provided to the respondent);
a copy of Form 4 received from the claimant.
For the purposes of section 28LZA(1)(a) of the Wrongs Act 1958, the prescribed form is Form 5 in Schedule 1.
Schedule 1—Forms
Form 1
Regulation 5
CERTIFICATE OF ASSESSMENT OF DEGREE OF IMPAIRMENT ARISING FROM STABILISED INJURY
Wrongs Act 1958
Section 28LN
DETAILS OF MEDICAL PRACTITIONER
Name:
Qualification:
Address:
Telephone:
Email:
CERTIFICATION
I certify that on: [date] I examined: [insert name of person seeking the assessment]
of: [address of person seeking the assessment]
and I am satisfied/I am not satisfied [delete whichever inapplicable] that:
[*tick appropriate box/boxes]
*🞏 the degree of impairment resulting from this person's injury (other than psychiatric injury) satisfies the threshold level.
Brief description of injury assessed:
*🞏 the degree of impairment resulting from this person's psychiatric injury and symptoms (which has not arisen as a consequence of, or secondary to, a physical injury) satisfies the threshold level.
Brief description of psychiatric injury assessed:
SIGNED: DATED:
Please note:
This certificate must be provided by a medical practitioner who is an approved medical practitioner within the meaning of section 28LB of the Wrongs Act 1958.
This certificate must not state the specific degree of impairment.
Impairment is defined in section 28LB of the Wrongs Act 1958 to mean permanent impairment.
Threshold level is defined in section 28LB of the Wrongs Act 1958 to mean—
in the case of injury (other than psychiatric injury or spinal injury), impairment of more than 5 per cent;
in the case of psychiatric injury, impairment of 10 per cent or more;
in the case of spinal injury, impairment of 5 per cent or more.
The degree of psychiatric impairment must not have regard to any psychiatric or psychological injury, impairment or symptoms which has arisen as a consequence of, or secondary to, a physical injury—see section 28LJ of the Wrongs Act 1958.
Form 2
Regulation 6
CERTIFICATE OF ASSESSMENT OF DEGREE OF IMPAIRMENT WHERE INJURY HAS NOT STABILISED
Wrongs Act 1958
Section 28LNA
DETAILS OF MEDICAL PRACTITIONER
Name:
Qualification:
Address:
Telephone:
Email:
CERTIFICATION
I certify that on: [date] I first examined: [insert name of person seeking the assessment]
of: [address of person seeking the assessment]
in relation to [*tick appropriate box/boxes]
*🞏 an injury (other than psychiatric injury).
Brief description of injury assessed:
I certify that I have conducted a subsequent examination today in relation to the same injury and I am unable to determine the degree of impairment. However, I am satisfied that the degree of impairment resulting from this injury (other than psychiatric injury) will satisfy the threshold level once the injury has stabilised.
*🞏 a psychiatric injury.
Brief description of psychiatric injury assessed:
I certify that I have conducted a subsequent examination today in relation to the same psychiatric injury (which has not arisen as a consequence of, or secondary to, a physical injury) and I am unable to determine the degree of impairment. However, I am satisfied that the degree of impairment resulting from this psychiatric injury will satisfy the threshold level once the injury has stabilised.
SIGNED: DATED:
Please note:
This certificate must be provided by a medical practitioner who is an approved medical practitioner within the meaning of section 28LB of the Wrongs Act 1958.
This certificate must not state the specific degree of impairment.
Impairment is defined in section 28LB of the Wrongs Act 1958 to mean permanent impairment.
Threshold level is defined in section 28LB of the Wrongs Act 1958 to mean—
in the case of injury (other than psychiatric injury or spinal injury), impairment of more than 5 per cent;
in the case of psychiatric injury, impairment of 10 per cent or more;
in the case of spinal injury, impairment of 5 per cent or more.
The date of the first examination of the person seeking an assessment must be at least 6 months before the date of this assessment.
The degree of psychiatric impairment must not have regard to any psychiatric or psychological injury, impairment or symptoms which has arisen as a consequence of, or secondary to, a physical injury—see section 28LJ of the Wrongs Act 1958.
Form 3
Regulation 7
AGREEMENT TO WAIVE ASSESSMENT OF IMPAIRMENT
Wrongs Act 1958
Section 28LO(1A)
1. CLAIMANT'S NAME
Claimant's full name:
2. CLAIMANT'S DETAILS
Go to Part 3 if the claimant has a legal representative.
Claimant's address:
Claimant's telephone number:
Claimant's email:
Claimant's date of birth:
3. CLAIMANT'S LEGAL REPRESENTATIVE'S DETAILS
Go to Part 4 if the claimant does not have a legal representative.
Legal representative's name:
Legal representative's address:
Legal representative's telephone number:
Legal representative's email:
4. DETAILS OF RESPONDENT/S
For each party that the claimant considers is a proper respondent to the claim, provide the following information:
Name of respondent:
Address of respondent:
Telephone number of respondent: [leave blank if not known]
Reason why claimant asserts the respondent is the proper respondent to the claim:
Name:
Address:
Telephone number: [leave blank if not known]
Reason why claimant asserts this party is the proper respondent to the claim:
Name:
Address:
Telephone number: [leave blank if not known]
Reason why claimant asserts this party is the proper respondent to the claim:
This Part of Form 3 may be expanded as necessary to allow the details of all proper respondents to the claim to be included in the Form.
5. DESCRIPTION OF THE INCIDENT
Date of incident:
Time of incident:
Location of incident:
Description of incident:
6. THE INJURY TO THE CLAIMANT
Set out all the injuries claimed to have been suffered by the claimant as a result of the incident:
Provide details of the non-economic loss suffered by the claimant as a result of the injury:
Under section 28LB of the Wrongs Act 1958, non-economic loss is defined to mean any one or more of the following—
pain and suffering;
loss of amenities of life;
loss of enjoyment of life.
7. DOCUMENTATION OF THE INCIDENT AND INJURY
If the claimant intends to rely on a report of the incident to make the claim:
Date of report:
Name of person to whom the report was made:
8. DETAILS OF MEDICAL PRACTITIONER/S
If the claimant has been treated by a medical practitioner in relation to the injury:
Name of medical practitioner:
Professional qualifications of medical practitioner:
Address of medical practitioner:
Telephone number of medical practitioner:
Email of medical practitioner:
If a claimant has been treated by more than one medical practitioner, this Part of Form 3 may be expanded to include the details of any additional medical practitioners.
9. CERTIFICATION BY CLAIMANT (or claimant's legal representative)
Signature of claimant:
Date:
OR:
Signature of claimant's legal representative:
Date:
Respondent must respond in writing to the claimant within 60 days.
Under section 28LO(2) of the Wrongs Act 1958, a respondent who has received this Form must respond in writing to the request within 60 days of receiving it.
Form 4
Regulation 8
CLAIMANT PRESCRIBED INFORMATION FORM
Wrongs Act 1958
Section 28LT(2)
1. CLAIMANT'S NAME
Claimant's full name:
2. CLAIMANT'S DETAILS
Go to Part 3 if the claimant has a legal representative.
Claimant's address:
Claimant's telephone number:
Claimant's email:
Claimant's date of birth:
3. CLAIMANT'S LEGAL REPRESENTATIVE'S DETAILS
Go to Part 4 if the claimant does not have a legal representative.
Legal representative's name:
Legal representative's address:
Legal representative's telephone number:
Legal representative's email:
4. DETAILS OF RESPONDENT/S
For each party that the claimant considers is a proper respondent to the claim, provide the following information:
Name of respondent:
Address of respondent:
Telephone number of respondent: [leave blank if not known]
Reason why claimant asserts the respondent is the proper respondent to the claim:
Name:
Address:
Telephone number: [leave blank if not known]
Reason why claimant asserts this party is the proper respondent to the claim:
Name:
Address:
Telephone number: [leave blank if not known]
Reason why claimant asserts this party is the proper respondent to the claim:
This Part of Form 4 may be expanded as necessary to allow the details of all proper respondents to the claim to be included in the Form.
5. DESCRIPTION OF THE INCIDENT
Date of incident:
Time of incident:
Location of incident:
Description of incident:
6. THE INJURY TO THE CLAIMANT
Set out all the injuries claimed to have been suffered by the claimant as a result of the incident:
Provide details of the non-economic loss suffered by the claimant as a result of the injury:
Under section 28LB of the Wrongs Act 1958, non-economic loss is defined to mean any one or more of the following—
pain and suffering;
loss of amenities of life;
loss of enjoyment of life.
7. DOCUMENTATION OF THE INCIDENT AND INJURY
If the claimant intends to rely on a report of the incident to make the claim:
Date of report:
Name of person to whom the report was made:
8. DETAILS OF MEDICAL PRACTITIONER/S
If the claimant has been treated by a medical practitioner in relation to the injury:
Name of medical practitioner:
Professional qualifications of medical practitioner:
Address of medical practitioner:
Telephone number of medical practitioner:
Email of medical practitioner:
If a claimant has been treated by more than one medical practitioner, this Part of Form 4 may be expanded to include the details of any additional medical practitioners.
9. CERTIFICATION BY CLAIMANT (or claimant's legal representative)
Signature of claimant:
Date:
OR:
Signature of claimant's legal representative:
Date:
Respondent must respond in writing to the claimant within 60 days.
Under section 28LW(1) of the Wrongs Act 1958, a respondent on whom a copy of a certificate of assessment is served must respond in writing to the claimant within 60 days after receiving the certificate and the required information under section 28LT.
If the respondent fails to respond in writing within the 60 days, the respondent is deemed to have accepted the assessment (section 28LW(4)).
Form 5
Regulation 9
NOTICE OF REFERRAL OF MEDICAL QUESTION TO MEDICAL PANELS
Wrongs Act 1958
Section 28LZA(1)(a)
1. MEDICAL QUESTION
*🞏 Does the degree of impairment resulting from the physical injury to the claimant alleged in the claim satisfy the threshold level?
*🞏 Does the degree of impairment resulting from the psychiatric or psychological injury to the claimant alleged in the claim satisfy the threshold level?
[*tick appropriate box/boxes]
2. RESPONDENT'S DETAILS
Respondent's full name:
Respondent's address:
Respondent's telephone number:
Respondent's email:
3. RESPONDENT'S LEGAL REPRESENTATIVE'S DETAILS (if applicable)
Legal representative's name:
Legal representative's address:
Legal representative's telephone number:
Legal representative's email:
4. RECEIPT OF INFORMATION FROM CLAIMANT
Date on which the respondent received the certificate of assessment:
Date on which the respondent received Form 4 from the claimant:
5. ATTACHED DOCUMENTS
The following documents must be included as attachments to this Form:
🞏 Certificate of assessment received from the claimant
🞏 A copy of Form 4 received from the claimant
🞏 Statement of claim (if received from the claimant)
6. CERTIFICATION BY RESPONDENT (or respondent's legal representative)
🞏 I have advised the claimant that I have referred a medical question in relation to the assessment to a Medical Panel for determination.
Signature of respondent: Date:
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