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Aids and Equipment Program. (A&EP)

Application For Aids And Equipment

LGA (local council)

Next of Kin / Contact Person / Relationship to client

Next of Kin Address Telephone H

W

DISCIS Registration Number (if applicable)

1. Are you applying for a breast / mammary prosthesis? Yes (go to Q3) / No

2. Do you have a disability of a permanent or indefinite nature? Yes/No

If yes, diagnosis.................................................…………………………………………….

3. Are you a permanent resident of Victoria? Yes / No

4. Are you of Aboriginal or Torres Strait Islander origin? Yes / No

If yes, please indicate..............................................…………………………………………....

5. Are you receiving a pension / Child Disability Allowance? Yes / No

6. Are you in receipt of a Health Care card? Yes / No

7. Are you in receipt of a Medicare Card? Yes / No

If yes, please specify

Pension Number

Health Care Card

Medicare Number

8. What is your preferred language? ..................................……………………………....

9. Have you received/are you eligible or currently receiving assistance through:

(Please specify date and cover received if the answer is Yes to any of the questions below)

a) Department of Veteran Affairs?(specify card type) Yes / No

b) WorkCover Yes / No

c) Transport Accident Board Yes / No

d) Legal claim Yes / No

e) Commonwealth Rehabilitation Program Yes / No

f) Commonwealth Education Program Yes / No

g) Other Government funded scheme (specify) Yes / No

h) Private health insurance with extras (name) Yes / No

i) Continence Aids Assistance Scheme (CAAS) Yes / No

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10. Have you been treated as a public hospital in-patient within the past 30 days? Yes/ No

If Yes, please specify:

Date of discharge:

Name of Hospital:

Reason for admission:

11. Are you currently a resident of:

a) Private nursing home (specify) Yes / No

b) Hostel (specify) Yes / No

c) Supported residential accommodation service (specify) Yes / No

d) Private / Public hospital (specify) Yes / No

e) Unit providing subsidised care (specify)

(eg. CRU, group home, Training Centre)

Yes / No

If yes please specify.

12. Have you received previously assistance under any

AIDS & EQUIPMENT PROGRAM (A&EP)? Yes / No

If Yes:

Type of aid/equipment Date received A&EP Service Provider

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Details of Aids and Equipment Requested

(Assessment, documentation, supplier and costs involved must be attached)

See attached page 4 for details.

Delivery Address

Name:

Address:

Contact person Phone No:

Assessor Details

Name: Profession:

Address

Contact Phone No:

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Declaration

I confirm that my signature below represents:

My agreement to enquiries being made by the Department of Human Services or it’s agent, to

other individuals and organisations, for the purpose of obtaining information about eligibility

and assessment for the requested Aids and equipment.

• My understanding that all the information I have supplied on this application is true and correct to the best of my

knowledge.

• My understanding that this application is not a formal approval or guarantee of A&EP

• services.

• My understanding that the A&EP is not available to people who have received compensation or damages in

respect of their disability. But if the prospective recipient has made, or is intending to make such a claim, the A&EP

service provider shall serve on the recipient notice of liability on the part of the recipient to pay the A&EP service

provider a sum equal to the cost of the equipment, and the A&EP service provider will seek to arrange for those

liabilities to be included in recipient's claim for damages.

Client Signature..........................................................……………………………………….….Date.............................

AND

CONFIRMATION OF DISABILITY (Signature of one of the following required)

DOCTOR: ...............................................................…... Phone: ....................……………….. Date:...................……..

(initial confirmation of disability only)

ASSESSOR: ................................................................. Phone: ................. .....…………..….Date: ...............……......

(ongoing confirmation of disability)

DISABILITY SERVICES: ......................................…….. Phone: ...............……… ……....... Date: ...…………...........

(confirmation of disability for people with an intellectual disability, signed by Manager Accommodation

Services or Manager, Disability Client Services)

A&EP Agreement to pay balance

I, ______________________________________ agree to pay direct to the supplier/contractor, upon receipt of his

invoice, the balance of approximately $ ______________ for the supply of A&EP equipment/home modifications,

where the cost exceeds the ceiling of $400 for shoes and $200 for insoles set by Department of Human Services,

Community Access, for the equipment/home modifications.

I understand that this contribution is non-refundable.

I also understand that pending availability of A&EP funding, this request will be placed on a waiting list. If a price

increase occurs prior to the order being placed, A&EP funding will remain at $ ______________ .

I also acknowledge and understand that the supplier has the right to request payment of the above amount prior to

delivery of the equipment.

_____________________________________ (Patient Signature)

_____________________________________ (Date)

_____________________________________ (Witness)

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Details of Aids and Equipment Requested

(Bradma)

Diagnosis / relevant history and foot problem

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

(The following box is relevant for footwear requests only)

Current footwear and relevant history:

_____________________________________________________

_____________________________________________________

_____________________________________________________

New Request

Replacement request

Date of last supply

Yes No

Yes No

____________

Check the following characteristics for the required shoe

Does the client have a foot deformity? Yes No

Can client’s clinical needs be adequately met with shoes available through retail footwear

outlets? Yes No

Are the shoes required to accommodate insoles / AFOs? Yes No

Extra-depth / width Yes No

Does the extra depth shoe have a depth > 6mm in the toe box and back height?

Yes No

Is the shoe width > E fitting? Yes No

Custom-made Yes No

Item Required (with description) Supplier Quote

Has a follow-up visit been arranged to inspect suitability of shoes / insoles before use? (please circle) Yes No

Prescriber: ____________________________________ POD /P&O Telephone: ___________________________

Address: ____________________________________ E-mail: _______________________________________

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