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Direct Order Form

RAP Mobility & Functional Support Products

Provider Hotline Number: 1300 550 457 (metro) 1800 550 457 (country) - choose Option 1 for Aids & Appliances provided under the Rehabilitation Appliances Program (RAP).

This form is to be used for requesting items through the Rehabilitation Appliances Program. For prior approval items, please attach clinical justification or use DVA specified forms.

The provider is responsible for ensuring that the client is aware that their personal information is to be forwarded to DVA, and companies authorised by DVA to deliver products, for determining and/or providing benefits under the Veterans’ Entitlements Act 1986. The information will be treated in a confidential manner. However, in certain circumstances it may be used for clinical review, audit or management purposes or disclosed to the client’s local medical officer.

Supplier choice:

Aidacare

Allianz Global Assistance (Mondial)

Country Care Group

Invacare

ParaQuad

Provider Details

OT

RN

PT

LMO

Other (Specify Profession)

Provider Stamp (if applicable)

Name Provider number

Employer Address

POSTCODE

Phone number

[

]

Fax

[

]

Mobile number E-mail

Surname Given name(s)

Date of birth

/

DVA file number Gender

Male

Entitled Person/Delivery Details

/

Female

Card type

Gold

White - please contact DVA to check eligibility under the client’s Accepted Disability(ies). Please call 1300 550 457 (as above).

Does the entitled person live in a Residential Care Facility?

Does the entitled person receive help under the EACH package?

No

No

Yes - what category of care?

Yes - please contact DVA

Low 5 - 8 High 1 - 4 (refer to DVA)

Entitled person’s contact phone number

[

]

Alternative contact No. []

Residential address

POSTCODE

Delivery address (if different to above)

POSTCODE

D992 - 05/11 - P1 of 3

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