This form is used to request a trial of Level 2 equipment in the client’s home or community. The request may be for the provision of DEP equipment in stock or for funding to loan/hire or freight items for trial purposes. Approved Prescribers will be notified of request outcomes and are then responsible for ordering and arranging delivery of trial items.
SECTION 1 (To be completed by Approved Prescriber)
Client Details
Client ID: / Is the applicant an existing DEP client? / Yes / No / Unsure
CRN (Pension No.): / A DEP Application Form is required for all new applicants, and existing clients whose situation has changed or requires confirmation (Financial Hardship).
Surname: / Given Names: / Date of Birth: / /
Address:
Parent/Guardian Details
Name: / Relationship:
Address (if different to client):
Identification Of Need/Trial Details
Brief justification of trial/identification of need:
Proposed trial details (include length (maximum of two weeks) and start/end dates if known):
Clinical Prioritisation: 1 Essential 2 Improve/maintain 3 Therapeutic/contributes
(This is an indication of the clinical priority for the item and should be justified above)
Equipment Details (attach itemised quote/s)
Item Name and Description/Service / Supplier/SEAT Service/ Freight Co./Stock / Trial Cost
(if applicable)
Prescriber Details
Name: / Work Unit:
Approved Prescriber No.: / Contact Phone:
Signature: / Date:
Ø Approved Prescriber forwards to A&DP Centralised Intake for processing. If eligible for DEP, Intake forwards to Cost Centre Manager.
SECTION 2 (To be completed by DEP Cost Centre Manager)
Cost Centre Manager Approval (as per Financial Delegations)
Approved Prescriber registration confirmed? Yes No If No, contact prescriber
AP Number format: DEP Admin Number - Level and Equip Type – Level and Equip Type eg. 52-G1SPMW-G2V
Approved / Not Approved
Comments/Outcome:
Name: / Title:
Signature: / Date:
Ø Cost Centre Manager forwards to DEP Work Unit for processing. DEP notify the Approved Prescriber of the Trial Request outcome.
Aged and Disability Program | T1 Version: 1.0 Page 2 of 2 Created: March 2012 | Review: March 2013
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