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Surname

DVA File number

Hospital Discharge Details (Please fill out this section where equipment is related to the entitled person’s discharge from hospital)

Item is required for discharge

Item is a fixture

Date of discharge

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Order Details (Prescriber to complete)

Please refer to RAP Schedule of Equipment http://www.dva.gov.au/service providers/rap/Documents/RAPNatScheduleEquipment151110new.pdf

RAP

Product

Schedule No.

Catalogue No.

Size

Type

Specifications

Quantity

Home Owner agreement to installations (e.g. rails).

Signature

I certify that the client has been clinically assessed and that the RAP National Schedule of Equipment and RAP National Guidelines have been taken into account.

Signature

For prior approval items, please attach clinical justification or use DVA specified forms (see RAP Schedule)

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Date

/

Date

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D992 - 05/11 - P2 of 3

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