Name: DOB:
1. CLIENT INFORMATION
Client Name / Last Name
First Name / ENABLE #
Aids and Equipment Program
SEED HRP
PLS
Title / Mr Mrs Ms Miss
Other / Date of birth
Email
Address / Suburb Postcode
Phone / Mobile
Contact person (if not client) / Contact details
2. CHANGE TO EXISTING REQUEST
2 a) What category of equipment or consumables is being changed?
Continence / HEN/Voice Prosthesis General Equipment Prosthetic Respiratory
2 b) What is being changed?
2 c) What is the reason for the change?
Equipment item is no longer available
Carer or environment of use has changed
Client’s needs have changed.
Other Please provide details
3. DETAILS OF CHANGE
3 a) Equipment/Product – specific type and size required / Supplier details or non contract details / Quantity / Cost
(inc GST & Del)
1. / $
2. / $
3. / $
4. / $
3.b) Describe how the features/specifications of the recommended equipment will meet the client’s need in the most cost effective, clinically appropriate way
3 c) Trial of recommended equipment: Describe the duration, location and outcome of trial. If trial was not conducted please explain.
3 d) Is the client/carer aware of and in agreement with this change?
Yes Date agreement received:
No N.B. Application will only be processed with client/carer agreement.
3 e) A copy of the revised equipment request has been given/sent to the client.
Yes No if not why?
Date
DECLARATION (Tick 1 box only)
I declare that I have assessed the client and have the required qualification and level of experience to prescribe this equipment according to the Professional Criteria for Prescribers.
I declare that I have assessed the client and have been supervised by
who meets the Professional Criteria for Prescribers to prescribe this equipment and has agreed to be nominated as my supervisor for this prescription.
I declare that I have assessed the client and that I am approved by my service to prescribe this Group 1 equipment. Name of service
This equipment has been prescribed by the treating multi-disciplinary team on
and I have completed the equipment request on behalf of that team. Team included:
I declare that I have assessed the client and am an Approved Prescriber of this group of equipment.
Prescriber name:
Address:
Phone:
Email: / Signature:
Qualification:
Days/Hours available:
Date:
I am the same person who made the original equipment request Yes No
Supervisor name: (if required)
Address:
Phone:
Email: / Signature of supervisor (if practical):
Qualification:
Days/Hours available:
Date:

N.B. Incomplete forms will be sent back. Please ensure all contact details are provided.

EnableNSW Ammendment to Existing Equipment Request July 20011 Page 2 of 2