Health Service PATS Cover Sheet

The cover sheet must be completed with all PATS following IHPT/PE forms

Patient’s PATS Office(see contacts) / Discharging health service
To: / From:
Region: / Ward: / Full name:
Phone: / Phone:
Sent via: / Preferred return contact method:
Fax: / Fax:
Email: / Email:
# Of fax pages: / Date:

Dear PATS Clerk,

Please arrange transport for

on date ____/_____/____

The following checklist is to assist the Health Service in the discharge of PATS patients:

Checklist / YES / NO
The patient is making their own way home and will contact you at a later date(before 8 weeks)to claim reimbursement
Completed PATS following IHPT/PE form attached
Completed Fitness to Fly form (if required) attached
Requires wheelchair to seat - please inform airline of hoist requirement
Clinically assessed as requiring escort
Patient Identification (photo or 3 forms of non photo ID, such as bank cards, Medicare card - If not, please inform airline)
The Patient is staying in Perth and will contact you at a later date to arrange transport
Patient has been provided with PATS contact details if applicable
Other requirements for travel e.g. oxygen
Please specify

Kind regards, ______

First name last name

PATS following IHPT/PE form May 2017

Patient Assisted Travel Scheme (PATS)followingInter Hospital Patient Transfer or Primary Evacuation (IHPT/PE)form

This form is to be completed by the discharging health service and emailed/faxed to the patient’s PATS office for approval and booking of return travel at the earliest possible time prior to discharge.

Section A: Patient details
URMN: / Medicare No:
Full name: / DOB: / Sex: M / F
Permanent residential address:
Patient is returning to: permanent residential address as above
If different please state:
Patient’s phone: / Perth contact phone:
Did the PATS patient make a planned trip to the Hospital using pre-approved PATS Assistance? / YES If YES skip to Section C
NO If NO complete Section B
Section B: PATS eligiblity for IHPT/PE patients
Nb: Patients who were Inter Hospital Patient Transfers / Primary Evacuations need to be assessed for PATS Eligibility.
Patient was IHPT/PE FROM:
Is the Patient eligible for assistance through any other program, or is a compensation or insurance claim pending? / YES / NO
If yes, please specify: / Workers Compensation / Motor Vehicle Accident / Veteran Affairs
Details:
Patient eligible for PATS if Yes to ALL of the following: YES NO
Patient came to Perth by IHPT/Primary Evacuation
Patient is permanent country resident eligible for Medicare
Patient is returning to permanent residential address or somewhere closer(NB: NOT PATS if being transferred back to country hospital)
Patient resides > 100km from the discharging Hospital
NB:If NO to any of the criteria please contact the patients PATS Office for advice.
Section C: Discharge details
Admission date: / Discharge date:
Consultant: / Specialist:
Patient will travel by: / car / bus / train / AIR (eligible if patient resides in Pilbara or Kimberley region
OR surface travel >16 hours OR clinical reason)
If travel by AIR must state clinical reason for approval:
Concession Card number (if applicable) for discounted travel: EXP:
Does the patient require an escort? / YES FULLName: / NO
If YES must state clinical reason for approval:
Does the patient require accommodation external to the hospital prior to travel? / YES / NO / If yes provide dates:
TO
Any additional information required?
Signature of Medical Specialist/Clinical Nurse Specialist:Date: