Important Information About This Application

Prostheses List

Request to Amend a Listing

Human Tissue

Important Information about this application

Assistance to complete this application

The Prostheses List – Guide to listing and setting benefits for prostheses (the Guide) provides important information and guidance on how to make an application to list a prosthesis, including definitions for terminology used in this form. Refer to the Guide as you complete this application to ensure the information and documentation you provide complies with the application requirements.

Contact the Prostheses Secretariat:

Phone: (02) 6289 9463

Email:

A request to amend the listing of a human tissue item on the Prostheses List should be submitted via the Prostheses List Management System (PLMS) portal whenever possible and practical. The PLMS portal is at

If PLMS is not accessible, a request can be submitted on this form.

Where to send applications

Please email applications and attachments to:

Prostheses Secretariat

Private Health Insurance Branch

Department of Health

December 2015 (TRIM E15-11269)

Request to amend a listing – human tissue

Secretariat use ONLY:

APPLICATION NUMBER/S:

Date Received:

Entered on Administration Database:Date:Initials:

Application checked:Date:Initials:

NOTE: Mandatory fields in the application are denoted with an asterisks (*) symbol.

Sponsor’s contact information for this application

Sponsor name: *

Sponsor ABN: *

Primary Contact

Full name and position: *

Phone number - Office: *

Phone number - Mobile:

Email: *

Secondary Contact (optional)

Full name and position:

Phone number - Office:

Phone number - Mobile:

Email:

Amend Human Tissue

Current Product Details

Billing code: *

Product name: *

Description: *

Please select the main reason for the amendment: *

Change in benefit

Change to the description

Change in size(s)

Proposed product details

Product name: *

Description: *

Size(s): *

Proposed benefit: *

If you have applied to change the benefit amount, please explain how you calculated this benefit: *

(supporting documentation must be attached if you are applying to change the benefit amount)

ARTG ID Number

Please identify the ARTGID details below for your product: *

ARTG ID / Sponsor Name / ARTG Entry Name / Class

OR

☐Alternatively, tick here if you have applied to include your device on the ARTG (ARTG ID Number is pending)

Category

Please nominate the category in which you wish the product to be listed: *

Attachments

Listed below are attachments related to your application. Please include all relevant files when submitting your application.

Required attachments:

-An image of the product/item

Optional attachments:

-Documentation to support the proposed change of product name and/or description

-Annual Financial Statement – certified by an accountant (if a change in benefit is sought)

-Audit of Service Cost Calculation – certified by an accountant (if a change in benefit is sought)

Submission Declaration

☐I declare that all information provided in this application is true and correct.*

☐I declare that the proposed benefit for this human tissue item(s) is calculated on a cost recovery basis only, and compliant with relevant State or Territory legislation.*

December 2015 (TRIM E15-11269)