This guideline outlines the procedure for completing an NDIA prescription form.
Section on Form / InterpretationParticipant NDIA ID No / Provide participantNDIA identification number.
Participant Details / State participant’s name, date of birth, phone number, usual address. These are all required in order to process the prescription.
Participant weight / Select one tick-box. If weight may increase rapidly, resulting in item no longer suitable, indicate a higher weight. Educate participants/families to contact DES or their clinician if weight gain leads to item being no longer suitable.
Prescriber name / Name of prescribing clinician
Discipline / State the prescriber discipline
Email / Required for notification when item delivered
Phone or fax / Provide phone or fax number
Instructions
Special Needs / Delivery / Installation / If require DES to contact Prescriber before delivery, tick box. Add details re:
- extra features or accessories to be fitted to ordered items
- location in home / room where items need to be installed
- height items need to be adjusted to
- joint visit & future delivery date to coincide with visit, if required
- family to be instructed NOT to use the item until the clinician visits
- specific to item delivery, such as “use back entrance as nil steps”
- whether a rental item is requested as an interim pending supply of another item
Contact person for delivery / The contact person (and their phone number) with whom DES should liaise re delivery. This will usually be the participant/carer but may be the clinician
Delivery address / Provide the delivery address, if different from the participant’s usual address
Safety precautions/alerts / MUST be completed. List any safety issues that Equipment Liaison Officers may encounter when delivering equipment or write “nil alerts”. This information is not visible on client copies of delivery documents.
Delivery timeframe / Select one of the following:LOW: 5 working days / MEDIUM: 3 working daysHIGH: 1 working day / URGENT: same day (if sent by 12noon) Only if extreme circumstances.
Preferred delivery time / Select AM, PM or Any. Exact time is not given, as not always achievable
DES Catalogue Item code / State the item code from the DES Equipment Catalogue on the DES website. If no code available leave blank.
Equipment requested / Specify item type required. If code not available on the DES Equipment Catalogue, provide general specifications required to meet participant’s requirements to enable matching of required item from the DES store. If a particular brand is required, supporting rationale needs to be provided.
Support item on participant’s plan / Select “YES” to indicate that the support item is on the participant’s plan. Either the participant or planner can assist in confirming this. Items can only be provided if they are on the participant’s plan.
Quantity / List the quantity required (or select number from drop down box)
Replacement item / Select “YES” if client has requested type of equipment needing replacement
Substitute / Select “YES” if requested item can be substituted for one with similar function / purpose but different brand / features.Only like items will be substituted.If client has a specific need for a particular model of equipment that is stocked by DES, enter “NO” in the substitution box
Trial only / Select if request is for trial of item only, or for interim items supplied pending provision of another item. For trial items, the participant’s plan must include the ‘rental’ support line. Items can be trialled for 2 weeks after which the item will require being returned or issued on a standard support line. If item requires being issued, ensure that an appropriate support line is included on the participant’s plan.
Primary clinician / The primary clinician (who works with the client and first became aware of the equipment need) prints name, signs and dates here to indicate approval.
Completed Prescription forms (and the relevant Specification Form for customised items) are faxed as described on the form.