Assistive Technology Funding Application Form

Department of Communities, Disability Services

Assistive Technology Funding Application Form

This is the Assistive Technology & Home Modifications (AT&HM) funding application form for AT categories 2-4. For repairs/maintenance needs, please email the relevant Budget Holders.

The information provided in this form will be used to understand how the specified AT will support the achievement of the person’s goal and to assess whether it is reasonable and necessary.

AT Prescriber Service Provision:WA NDIS AT prescribers should adhere to the policy of reasonable and necessary funded supports in a plan and the relevant standards and guidelines in assistive technology prescription. The prescribers should also adhere to the Service Agreement with the WA NDIS.

Should concerns arise in the service provision, the person and the AT prescriber should communicate with each other in the first instance to resolve the concerns as agreed mutually.

Restrictive Practice: AT Prescribers must be aware of and observe the law with regard to AT options that are likely to restrain a participant. Where a person has a legally compliant behaviour support plan in place and the recommended option is consistent with that plan, WA NDIS may approve the AT but will require a review when the behaviour support plan is reviewed at least annually.

WA NDIS AT Complexity Levels 3 & 4: Where the AT prescriber and the person need to work with an AT supplier to trial and develop a specification for the support; reasonable supplier costs for trial can be quoted. This will be reviewed as per the Assistive Technology Pathway for trial suitability.

Co-contribution (“top up”): WA NDIS will generally only fund the minimum necessary or standard level of support required (i.e. a wheelchair with standard specifications and features, as opposed to funding additional items that are not related to the functional specifications required to meet the person’s goal). A person may choose to “top up” for such additional features as long as the equipment remains safe, effective and beneficial for use.

WA NDIS expects AT prescribers to consider all options to address the person’s disability related functional limitations and achieving goals, including non AT supports.

AT Prescriber signature:

AT Prescriber name:

Date:

PERSONAL DETAILS

Name
DOB
Address
Contact telephone number
Alternative Contact/Guardian
Local Coordinator email
Diagnosis
Note: WA NDIS considers AT related to the eligible diagnosis in the plan
Does the person’s WA NDIS plan have an AT strategy? / Y N
Relevant goal(s) in the WA NDIS plan

AT PRESCRIBER

You must be able to provide evidence of competence in prescribing this type and level of AT and the relevant assessments undertaken on request for auditing purposes

Name
Discipline & Qualifications
Business Name
Contact telephone number
Email address
Date (s) of assessment (s)
Date of application / PART 1 PART 2

AT REQUEST

Is this application urgent? / Y N
If yes, please state reasons
Description of item

PART 1 – EXPLORATION OF OPTIONS

□ See Following □See Attached Report

Background

Note participant’s circumstances including: age; disability; functional impact of disability (current and future); social supports; environmental considerations in general and with regard to use of AT; current equipment; and other factors that may affect the AT outcome (e.g. coexisting medical and health concerns, undergoing life transitions etc.).

Functional Assessment Findings

Assessment Findings / Features Required / Clinical Justifications

Are there any additional features required that is considered to be above the minimum or standard level of this support? Why?

Please note if the person has agreed to contribute to the additional costs

Options Considered

Please provide information on alternatives considered to achieve goal/s including use of other supports, approaches and reasons why they were not considered suitable.

Do NOT proceed to trial until the options listed have been assessed for clinical soundness and against the reasonable and necessary criteria.

Other Supports and Approaches Considered
e.g. skills building, compensatory techniques, other common electronics and household items etc. / Reasons for Unsuitability
AT Options Considered
(include brand name and model) / Reasons for Consideration / Estimated Cost / Supplier

Confirmation to proceed to trials and complete the remainder of this funding application (Part 2).

Date:

PART 2 – OUTCOMES

Trial Outcomes

Assistive Technology (include brand name and model) / Trialled (T) or Considered (C) / Trial Outcomes
Clinical reasoning for the options recommended, trialled and considered (e.g. short and long term benefits, value for money etc.) / Cost and Supplier

Itemised quotes with cost of the components/accessories listed must be attached with this application. If only one quote is available, please state reasons below:

Are there any other factors that need resolution in order to implement the above?

(e.g. behavioural support plan, further training, environmental modifications etc.)

Recommended AT Specification

Description of item

WA NDIS funding

/ $

Person cost co-contribution

/ $
Does the person agree to co-contribution? □ Y □ N
Quote Total (a + b) / $
Supplier details / Name of supplier:
Contact person:
Telephone number:
Email:
Delivery details (to inform suppliers) / Name of receiver:
Telephone number:
Email (if applicable):
Address for delivery:

The person must be provided with maintenance, servicing and troubleshooting information indicated for the AT to remain in good working order, including:

□ Information and contact details for repairs and maintenance needs

□ Manufacturer’s guidelines/Owner’s manual

□ Annual maintenance and schedule

□ Person is informed of the need for timely reporting and processing of repair needs

The person consented to the recommended AT and its specifications.

□ Yes

□ No

AT prescriber signature:

AT prescriber name:

Date: