The employer, insurer or vocational rehabilitation provider may ask the treating doctor for additional information. Before responding to such a request, the treating doctor should:

• establish that the worker’s consent has been obtained for the release of information (section for signing on the First Medical Certificate);
• determine how the information will be used, or for what purpose (this will help decide what information is relevant); and
• enquire in what form the information is required (i.e. report, consultation or verbal communication).

Medical reports may be used in a court of law. The reports may also be used at the Dispute Resolution Directorate to assist arbitrators resolve disputes.

A report is the formal representation of a doctor’s opinion. It is likely that reports will be read by patients and colleagues. When compiling a report, ask yourself the following questions:

• Have I obtained the appropriate consent to release information?
• Does the report respond to specific queries?
• Is it understandable to a non-medical reader?
• Is the opinion provided in the report objective and supportable by clinical findings?
• For clarity, would it help to include the specific questions being addressed in the report in the body of the response?
• Is the report provided in a timely fashion to assist in the claims process?