DVA Request/Referral

All information requested on this form should be provided.
Please complete the patient's details, including address and date of birth if file number is not known.
This form should be used by the referring provider to:
•	request prior approval from DVA, where necessary, for treatment services and the supply of rehabilitation appliances;
•	refer directly to another provider where prior approval from DVA is not required; and
•	request patient transport for travel to treatment services.
For detailed information on DVA's prior approval and other administrative requirements, please refer to the booklet "Notes for LMOs", or contact DVA by phone.
Where prior approval from DVA is required, please send the comprehensive clinical details to DVA. The clinical details should include diagnosis and clinical findings. Please do not staple the clinical details to the form. If the request for prior approval is urgent, please contact DVA by phone.
Full clinical details are particularly important in relation to requests for rehabilitation appliances.
Where referral is appropriate, please send the any necessary clinical details directly to the provider.
The LMO is responsible for checking the eligibility of patients to receive treatment at DVA expense.
White card holders are entitled to receive treatment at DVA expense for their accepted disabilities only.
DVA will not be responsible for costs incurred where prior approval requirements are not followed, where ineligible patients are treated, or where a patient is treated by a provider who is not authorised to provide treatment on behalf of DVA.
If an indefinite referral to a medical specialist is appropriate for a chronically ill patient, the period of referral may be noted on the form as "ind".
The TRIPLICATE of this form is the Transport Request Form. It should be completed and returned to DVA when necessary.
The information provided on this form is required to process this request/referral. In the event of inappropriate servicing or treatment, or unprofessional conduct, information may be disclosed to the relevant State or Territory Registration Board or professional body.

Transport Request Form
The patient should use their usual, most economical, mode of public or private transport when travelling to treatment services.
Official car or taxi transport for treatment purposes will be provided only if a medical officer certifies that such transport is medically essential and that the patient cannot use satisfactory alternative transport.
If the patient is able to use public or private transport, this can be arranged without reference to DVA. Eligible patients can be reimbursed for privately incurred travel expenses if the treatment is approved and the patient attended the nearest suitable provider.White card holders are only eligible for transport benefits in relation to treatment for their accepted disabilities.

Patient Details 
PLEASE COMPLETE THIS FORM ON YOUR COMPUTER THEN PRINT TO SIGN
Full Name: <<Patient Demographics:Full Name>>
Date of Birth: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Address>>
File Number: <<Patient Demographics:DVA Number>>
Patient's condition to be treated:<<Summary:Progress Notes (Selected)>> 

Requesting/Referring Providers name: <<Doctor:Name>>
Provider number: <<Doctor:Provider Number>>
Address: <<Practice:Address>>
Phone Number: <<Practice:Phone>>	Australian Government
Department of Veterans  Affairs
DVA Request/Referral
The Specialist/Allied Health Provider referred to should:
1)	complete their Provider Number details; and
2)	  attach the ORIGINAL of this form to their claim for payment.
DVA must be billed for the relevant Government approved fee as full payment for services provided under this referral.  No separate charge may be levied on an eligible patient.
DVA will not be responsible for costs incurred where prior approval requirements are not followed, where ineligible patients are treated, or where a patient is treated by a provider who is not authorised to provide treatment on behalf of DVA.
The DUPLICATE of this form should be attached to any further referral, and returned to DVA by that provider.	
Providers Signature:
<<Miscellaneous:Date (short)>>	Specialist/Allied Health Provider's name <<Addressee:Name>>
Provider number: 
Town/Suburb of Practice: <<Addressee:City>>
Type of service required: <<Type of service required >>
Please specify which profession/specialty or appliance the treatment requires. 
Please Indicate whether the patient is:  <<Please Indicate whether the patient is>>
Period of Referral: <<Period of referral >>	

Patient Details 
PLEASE COMPLETE THIS FORM ON YOUR COMPUTER THEN PRINT TO SIGN
Full Name: <<Patient Demographics:Full Name>>
Date of Birth: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Address>>
File Number: <<Patient Demographics:DVA Number>>
Patient's condition to be treated:<<Summary:Progress Notes (Selected)>>

Requesting/Referring Providers name: <<Doctor:Name>>
Provider number: <<Doctor:Provider Number>>
Address: <<Practice:Address>>
Phone Number: <<Practice:Phone>>	Australian Government
Department of Veterans  Affairs
DVA Request/Referral
The Specialist/Allied Health Provider referred to should:
3)	complete their Provider Number details; and
4)	  attach the ORIGINAL of this form to their claim for payment.
DVA must be billed for the relevant Government approved fee as full payment for services provided under this referral.  No separate charge may be levied on an eligible patient.
DVA will not be responsible for costs incurred where prior approval requirements are not followed, where ineligible patients are treated, or where a patient is treated by a provider who is not authorised to provide treatment on behalf of DVA.
The DUPLICATE of this form should be attached to any further referral, and returned to DVA by that provider.	
Providers Signature:
<<Miscellaneous:Date (short)>>	Specialist/Allied Health Provider's name:

Provider number:
 
Town/Suburb of Practice: 

Type of service required: Specialist/Rehabilitation Appliance/Allied Health/Other 
Please specify which profession/specialty or appliance the treatment requires. 
Please Inditare whether the patient is: In a nursing home/ an in-patient/ in a hostel 
Period of Referral: 	
	(Internal Note ***Please Note that manual entry is required  in the above if referring to more than 1 specialist/Allied Health Proivider) 

Patient Details 
PLEASE COMPLETE THIS FORM ON YOUR COMPUTER THEN PRINT TO SIGN
Full Name: <<Patient Demographics:Full Name>>
Date of Birth: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Full Address>>
File Number: <<Patient Demographics:DVA Number>>
Patient's condition to be treated:<<Summary:Progress Notes (Selected)>>

Requesting/Referring Providers name: <<Doctor:Name>>
Provider number: <<Doctor:Provider Number>>
Address: <<Practice:Address>>
Phone Number: <<Practice:Phone>>	Australian Government
Department of Veterans  Affairs
Transport Request - please read the information on the reverse of this page

Please specify the medical reason(S) why official or taxi transport is requested: <<Medical reason(S) why official/Taxi transport reque >>

Give medical reasons is the patient requires an attendant to travel to the treatment: <<Medical reasons the patient requires an attedant >>

Period transport required for: <<Period transport required for >>	
Providers Signature:
<<Miscellaneous:Date (short)>>	If transport is to be arranged by DVA, please complete the following: 
Appointment date: <<Transport appointment date >>
Appointment time: <<Transport appointment time>>
Place of appointment (include clinic/ward)- <<Transport place of appointment (include clinic/ward>>
Patients pick-up address: <<Transport - Patients pick-up address>>
Is a return journey required? <<Transport, is a return journey required >>
Is wheelchair transport required? <<Transport, Is wheelchair transport required>>