South Australian Compulsory Third Pary (CTP)
Notification of Motor Vehicle Injury Form 
The purpose of this form is to provide early notification to the Compulsory Third Party (CTP) Insurance Regulator, of an injury incurred in a motor vehicle crash so that general practitioners can receive early advice on payment for the management and coordination of care for patients who may require an Injury recovery care plan (IRCP).
1	This form is to be completed when and if:
•	your patient was injured in a motor vehicle crash that occurred in South Australia, and
•	your patient considers a motorist (other than your patient) was responsible for the crash, and
•	this is the first time your patient has seen a general practitioner in relation to injuries sustained in the crash, and
•	the initial consultation occurs within ten (10) weeks of the crash.
2	The form has two sections to be completed:
•	Section A is completed by the treating general practitioner with the consent of the patient,
•	Section B is completed by the patient.
3	If this form is applicable it should be forwarded immediately by email to CTP@sa.gov.au, together with your invoice for the fee of $38.50 (inclusive of GST) for the completion of the form and the fee for clinical consultation at the rate prescribed in the WorkCoverSA fee schedule.
4	The CTP Insurance Regulator will:
•	pay your invoice for completion and submission of this form and for the clinical consultation.
5	To seek additional payments for clinical fees, the patient is required to lodge a claims form via the CTP claims process. Please refer to www.ctp.sa.gov.au.
 If you have any queries about CTP insurance or how to complete this form please refer to www.ctp.sa.gov.au

Section A - General practitioner to complete
Family Name: <PtSurname>                                                                                                         Given name(s) <PtFirstName> <PtMidName>
Medical diagnosis or description of injuries:  <Medical diagnosis or description of injuries:>
Do you consider these injuries/conditions are consistent with the circumstances of the motor vehicle crash described to you? <you consider these inuries/conditions consistent with crash>
Are the injuries expected to be resolved within: <Are the inuries expected to be resolved within>
if the injuries are not expected to resolve over the next two (2) weeks and are likely to require ongoing medical management, consideration should be given to the completion of an Injury Recovery care plan at the next consultation if that consultation occurs within (12) weeks of the crash.

Patient Consent 

Your personal information is collected by the state and by the insurer underwriting your CTP insurance policy. For details about how your personal information will be handled see www.ctp.sa.gov.au/privacy. 
I (patient's full name) <PtFullName>                                                                                Hereby authorise and consent to the release by
Dr (GP's full name) <DrName>                                                                                           of this form to the CTP Insurance Regulator.
If I subsequently make a claim, I authorise and consent to the further release by the CTP Insuracne Regulator of this form to the CTP insurance provider who is managing my claim.
I acknowledge that Dr (GP's name) <DrName>                                                                has discussed this form and its purpose with me
and I understand that the information contained in this form is required for the purpose of early notification of my injury to the CTP Insurance Regulator and payment of the fee for my first clinical consultation in respect of my injury. 

GP Signature:                                                                                                                        Patient Signature:

<TodaysDate>                                                                                                                       <TodaysDate>

Section B - Patient to complete

Family name: <PtSurname>
Given names: <PtFirstName> <PtMidName>
Address: <PtAddress>
Date of birth: <PtDoB>
Medicare no: <PtMCNo>
Home phone no: <PtPhoneH>
Work phone no: <PtPhoneWk>
Mobile no: <PtPhoneMob>
Date of crash: <Patient to complete - Date of crash>
Has a police report been filed?  <Patient to complete- Has a police report been filed?>
In the crash were you the:  <Patient to complete - In the crash were you the>

Resgistration of vehicle you were in or on (if applicable): <Registration of vehicle you were in or on (if applicable):>
Place of crash (street and suburb): <Place of crash (street and suburb):>
Description of crash: <Description of crash:>

Details of motorist who was responsible for the crash(if known)
Surname: <Details of motorist responsible for the crash- Surname>
Given names: <Details of motorist responsible for the crash - Given names>
Address: <Details of motorist  responsible for the crash - Address>
Vehicle Registration: <Vehicle Registration:>

GP details - to be completed by the practice 

Date of next appointment, if applicable <Date of next appointment, if applicable>
GP name, practice name, address (of stamp):
<DrName>
<Practice>
<UsrAddress>

Phone no: <UsrPhone>
Fax no: <UsrFax>
Email: <PracEmail>

The patient is to be provided with a copy of this form