/ Equipment Service
Loan Agreement

This agreement is made between MND Victoria and the ‘client’ named below:

Client name
Client address

MND Victoria is committed to operating an Equipment Service (ES) that makes available a limited range of commonly used equipment and disability aids to people with MND who are registered with MND Victoria and living independently in the community within Victoria. The ES operates within the guidelines of the State-wide Equipment Program (SWEP) administered by the Department of Human Services.

This agreement applies to all MND Victoria equipment loans, hire and provision of non-retrievable items.The equipment available through MND Victoria is offered free of charge to people living with MND, including the cost of delivery and retrieval of goods. Certain low cost items are provided on a non-retrievable basis. MND Victoria will facilitate the short term hire for selected items when nominated as urgent by the referring Allied Health Professional (AHP), and MND VictoriaES is unable to meet the request.

  1. Clients must be registered with MND Victoria and sign this MND Victoria Equipment Service Loan Agreement.
  1. Clients are required to ensure that an MND Victoria Confirmation of Diagnosisform, completed and signed by their doctor or neurologist is returned to MND Victoria.
  1. Requests for equipment are only accepted via email from an AHP on theMND Victoria Equipment RequestForm. The referring AHP is responsible for ensuring client and carer(s)know how to use the equipment safely and correctly.
  1. Hired equipment will be replaced as soon as possible after an ES item becomes available. Where ever practicable, hired equipment will be the equivalent make and model to the ES loan item. Hired equipment will only be replaced by standard ES equipment. If the client is not satisfied with the replacement equipment provided by MND Victoria, they will need to make otherarrangements.
  1. MND Victoria staff will arrange for the dispatch and retrieval of items. Delivery and retrieval is subject to the scheduling priorities of the carriers.
  1. MND Victoria intends to pay once only for the delivery and retrieval costs of an equipment item. The client may be required to pay for subsequent deliveries and retrievals of the same type of equipment if the equipment was unable to be delivered on the first occasion because no-one was home to take delivery or the client changed their mind about wanting the particular item.
  1. The client or representative will be contacted prior to delivery or retrieval to arrange a suitable time.It is preferable for someone to be at home, however if this is not possible a secure location under cover must be nominated by the client or representative when the delivery is arranged.
  1. Selected low cost items are issued on a non-retrieval basis andare clearly marked as non-retrievable. They do not need to be returned.Disposal which can include donation to a local community group or nursing home.
  2. MND Victoria is responsible for all maintenance and repairs to its equipment. Any loss, damage or maintenance requirement should be reported immediately. Only maintenance and repairs authorised by MND Victoria and carrying an MND Victoria order number will be paid for by MND Victoria.
  1. MND Victoria does not provide an emergency repair service. If a malfunction to its equipment occurs outside usual working hours, that is likely to put the person with MND at risk then 000 should be contacted to request assistance. A message should be left on the MND Victoria telephone 98302122 advising of the issue. The person leaving the messagewill be contacted on the next working day to discuss appropriate action. The exception being, during the Christmas and New Year holiday period whenauthorisation is given to the Physiotherapy Department at Calvary Health Care Bethlehem to organise limited emergency repairs to MND Victoria equipment on loan to mutual clients.
  1. The client is responsible for maintaining equipment in a clean state while in use and prior to its return. Basic maintenance instructions are provided with each item. It is the client’s responsibility to maintain tyres at the correct operating pressure.
  1. No modifications are to be made to items without prior discussion with the Manager Support Services and subsequent written approval.Clients modifying equipment without prior approval may be charged for the cost of returning the item to its original state or its replacement. The needs of people requiring purpose built or modified equipment are met through SWEP.
  1. Clients are required to seek permission prior to taking equipment belonging to MND Victoria outside of Australia and agree to accept responsibility for the cost should repairs or replacement due to loss of equipment be necessary.
  1. All equipment, with the exception of non-retrievableitems,remains the property ofMND Victoria.
  1. The client or representative will advise MND Victoria when an item is no longer useful, appropriate or required.
  1. The availability of equipment through MND Victoria does not preclude application to SWEP for the provision of new or reissued equipment.

Agreement

This agreement is to be signed by the client or their nominated representative(please circle).

I, the undersigned, confirm that I have understood the content and intent of this document and agree to abide by it in good faith.

Name of nominated representative
(if signing on behalf of the client)
Signature
Date

Please keep one copy for your records and return the signed copy to

MND Victoria, c/- PO Box 23, Canterbury, Victoria 3126.

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