Information for medical practitioners completing the SIRA certificate of capacity/certificate of fitness

The certificate is the primary tool for the treating medical practitioner to communicate with all parties involved in the patient’s recovery.

Recovery

The certificate is focused on what your patient can do rather than what they can’t do.

Evidence shows that returning to activities of daily living and work promotes recovery and leads to better health outcomes.

Effective communication

A key element in successful recovery is effective communication.

Effective communication between you, the insurer, other treating practitioners and the patient’s employer will facilitate a timely and safe recovery.

For the purpose of recovery at/return to work, an employer may provide information about your patient’s work, whether modifications to existing work to accommodate their injury are possible, and whether alternative work is available.

Notes for completing the certificate

The treating medical practitioner is responsible for completing the certificate.

A thoroughly completed certificate minimises the likelihood an insurer will need to make contact with you to obtain additional information or clarification.

The certificate is used to facilitate a tailored approach to injury management, returning to activities of daily living and recovery at work planning.

The patient is responsible for providing a completed certificate to the insurer (or for workers compensation claimants this may be sent to the employer) to be eligible for weekly payments.

Section 1

This section may be completed by your patient or by yourself as the treating medical practitioner.

Injured person’s consent

For the purpose of workers compensation claims only, your patient must sign this section of the form to enable all relevant parties to communicate about your patient’s injury and claim.

Once it has been signed you should encourage your patient to give it to the insurer or employer (for workers compensation) without delay.

Section 2

This section must be completed by yourself as the treating medical practitioner.

Medical certification

This section should only be completed for the initial certificate or the first certificate completed by a new treating medical practitioner.

A clear medical diagnosis using acceptable medical terminology assists an insurer to make better decisions about a claim.

If your diagnosis is unclear please indicate your provisional diagnosis (pending further investigation) and then update this section once the diagnosis is confirmed.

Management plan for this period

This may include diagnostic investigations, specialist referrals or treatment service referrals recommended for the current period. The information you provide enables the insurer to know what services are required and what invoices to expect. It is also important you monitor and review the effectiveness of any treatment you recommend.

You may also indicate here if you recommend referral to a workplace rehabilitation provider. The insurer may then arrange the referral in consultation with your patient.

Capacity for activities

If your patient has capacity for their pre-injury work this section does not need to be completed. For all other patients, consider activities of daily living currently being performed.

Capacity for work

When certifying capacity for work, you should consider the health benefits of good work. It is expected that you will commence discussing recovery at/return to work with your patient from the first consultation.

The valuable information provided by you about your patient’s capacity for work will assist employers and insurers to identify suitable work, aiming to help your patient to recover at/return to work with appropriate support.

You will be certifying whether your patient has capacity for:

• all pre-injury work
• some type of work, or
• no current capacity for any work.

When certifying that your patient has capacity for some type of work, you must complete the hours and days and also the ‘capacity’ section.

If certifying that your patient has no current capacity for work, you must estimate the timeframe you expect they will have some work capacity.

The certificate should, in most instances, not exceed 28 days. If you wish to provide a certificate exceeding the 28 day time frame you will need to provide clinical reasoning to justify the longer time frame. This may be entered into the ‘comments’ section below the review date on the certificate.

When completing the ‘capacity’ section, you should focus on what your patient can do as that will better help the employer, your patient, and insurer in their efforts to facilitate recovery at/return to work.

Treating medical practitioner details

This section must be completed and signed by the treating medical practitioner completing the certificate.

If you agree to be the nominated treating doctor, you must tick the box agreeing to the role. Your agreement to be the nominated treating doctor means you agree to communicate with all relevant parties to manage your patient’s recovery at/return to work.

Section 3: Employment declaration

Your patient is required to complete this declaration and send it to their insurer (or for workers compensation claimants this may be sent to the employer).

This section does not involve you as the medical practitioner and does not need to be completed during your consultation.

The employment declaration does not need to be completed by a patient with a workers compensation claim if they are an exempt worker (police officers, paramedics, firefighters, coal miners and workers who make dust diseases claims).

Other considerations when completing the certificate

In accordance with the Medical Council of New South Wales medical certificates guidelines, a certificate may be issued subsequent to a patient being away from work. However, the certificate should:

• state the date the certificate was issued
• cover the period during which the doctor believes the patient would have been unfit for work (for example, the patient was treated at emergency and is now visiting their treating doctor at their earliest convenience).

Signing a false certificate may result in the doctor facing a charge of fraud.

Disclaimer

This publication may contain information that relates to the regulation of workers compensation insurance, motor accident third party (CTP) insurance and home building compensation in NSW. It may include details of some of your obligations under the various schemes that the State Insurance Regulatory Authority (SIRA) administers. However to ensure you comply with your legal obligations you must refer to the appropriate legislation as currently in force. Up to date legislation can be found at the NSW Legislation website www.legislation.nsw.gov.au.

This publication does not represent a comprehensive statement of the law as it applies to particular problems or to individuals, or as a substitute for legal advice. You should seek independent legal advice if you need assistance on the application of the law to your situation.

This material may be displayed, printed and reproduced without amendment for personal, in-house or non-commercial use.