Form · Personal Injury & Compensation

Wrongs Act Form 4, claimant's prescribed information: completion guide

Guide to Form 4, the claimant's prescribed information named on the Medical Panels Wrongs Act referrals page, including the section 28LZC(b) certification.

Kind: Form. A form to complete, or a guide to completing an official one.
Where it applies: Victoria
AI use: Yellow You and the tool draft together, with you directing. You check every statement you rely on.
Law stated as at: 23 October 2026
Status: Maintained. Checked on 23 October 2026 against the official form at medicalpanels.vic.gov.au and the 2 authorities it cites, for Victoria.
Version: 1
Source: Link to the official form. Licence: © State of Victoria. Link only: download the current form from the official page each time; do not copy or adapt it.

Where this comes from

The official form is published by medicalpanels.vic.gov.au; this page is a completion guide. Last checked on 2026-10-23.

When to use it

Use when a respondent is referring a medical question to a Medical Panel under the Wrongs Act and the claimant must supply Form 4. The referral itself is made by the person being sued. The claimant completes Form 4. Do not use this guide to complete Form 5.

Used for these tasks

Each task page says how far AI may help with the task and what the lawyer must review.

How AI may be used

The tool may index imaging, investigation results and a medication list already on the file for the lawyer to check against section 28LZC(b); the claimant or the lawyer completes Form 4 and the certification.

AI may

Index imaging, investigation results and medication details already on the file
Note whether a litigation guardian, an interpreter, cultural needs, or recent or upcoming surgery is already recorded

AI must not

Must not write Form 4. The Word file was not opened, so its questions are not described here
Must not write or sign the section 28LZC(b) certification
Must not complete Form 5 or the respondent's referral form
Must not describe Schedule 2. That PDF did not open

The lawyer checks

The Medical Panels page says a Wrongs Act referral is made by the person being sued, and that the pack includes Form 5, the Wrongs Act Referral Form 2025, copies of certificates of assessment, and Form 4 from the claimant
The claimant or the claimant's lawyer certifies, under section 28LZC(b), that all documents in their possession that relate to the medical question have been provided, including imaging and other investigation results and details of medications
A physical certificate leads to a physical assessment only. A psychiatric certificate leads to a psychiatric assessment only. Both certificates mean one Panel does both, and the assessments are not combined
Form 4 is the file the page names: Form-4-Claimants-prescribed-information-2025.docx on the Department of Justice site. Read it before it is used
Tell the Panel about a litigation guardian, an interpreter including dialect, special or cultural needs, and recent or upcoming surgery
Health information stays in a firm-controlled tool. Check ASCR r 9, APP 11, and whether any disclosure would be a notifiable breach under the Privacy Act 1988 (Cth).

Method: how the Green, Yellow and Red levels are decided. This is guidance for planning, not legal advice.

Authorities

Official form

Open the official form. Always use the current version from the issuer. Licence: © State of Victoria. Link only: download the current form from the official page each time; do not copy or adapt it..

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The summary, the law it rests on and the AI-use guidance above stay public. Privacy.

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