---
title: "Wrongs Act Form 4, claimant's prescribed information: completion guide"
url: "https://ailawframework.com/precedents/personal-injury-and-compensation/form-vic-wrongs-form-4"
type: "precedent"
site: "AI Law Framework"
id: "a21-form-vic-wrongs-form-4"
area_id: "A21"
kind: "form"
ai_level: "yellow"
version: 1
task_ids: ["A21-WR20261022-8", "A21-T1-R5"]
law_stated_as_at: "2026-10-23"
---

# 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.

Canonical page: https://ailawframework.com/precedents/personal-injury-and-compensation/form-vic-wrongs-form-4  
Law stated as at: 2026-10-23

Site index for agents: https://ailawframework.com/llms.txt

## Key facts

- Kind: Form. A form to complete, or a guide to completing an official one.
- Practice area: [Personal Injury & Compensation](https://ailawframework.com/precedents/personal-injury-and-compensation.md)
- Jurisdictions: Victoria
- AI level: Yellow. You and the tool draft together, with you directing. You check every statement you rely on.
- Law stated as at: 2026-10-23
- Status: Maintained. Checked on 2026-10-23 against the official form at medicalpanels.vic.gov.au and the 2 authorities it cites, for Victoria.

## 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

- [Test an injury against the significant-injury description](https://ailawframework.com/practice/personal-injury-and-compensation/test-an-injury-against-the-significant-injury-description.md)
- [Draft the pre-action notice or statutory claim form from the instructions](https://ailawframework.com/practice/personal-injury-and-compensation/draft-the-pre-action-notice-or-statutory-claim-form-from-the-instruction.md)

## 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).

## Authorities

- [Medical Panels Victoria, Wrongs Act referrals, naming Form 4 (opened 23 October 2026)](https://medicalpanels.vic.gov.au/make-a-referral/wrongs-act-referrals/)
- [Wrongs Act 1958 (Vic), version 130, in force 25 February 2026](https://www.legislation.vic.gov.au/in-force/acts/wrongs-act-1958/130)

## Official form

[Official form](https://medicalpanels.vic.gov.au/make-a-referral/wrongs-act-referrals/)

## 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.

## Full text and drafting notes

The full text and the drafting notes are not part of this public page. Signed-in firm accounts can read them at https://ailawframework.com/precedents/personal-injury-and-compensation/form-vic-wrongs-form-4 and through the signed-in MCP connector https://ailawframework.com/mcp/firm.

*Practice guidance for planning and review. Confirm current primary sources and the requirements of the actual matter. This is general information, not legal advice.*