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
Order Details (Prescriber to complete)
Please refer to RAP Schedule of Equipment http://www.dva.gov.au/service providers/rap/Documents/RAPNatScheduleEquipment151110new.pdf
Home Owner agreement to installations (e.g. rails).
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.
For prior approval items, please attach clinical justification or use DVA specified forms (see RAP Schedule)
D992 - 05/11 - P2 of 3