Order Form
   RAP Mobility & Functional Support Products 	

Provider Hotline Number: 1800 550 457 – choose Option 1 for Aids & Appliances provided under the Rehabilitation Appliances Program (RAP).
This form is to be used for requesting items through the RAP. For prior approval items and White Card holders, please attach clinical justification or use Department of Veterans’ Affairs (DVA) specified forms. 
Privacy notice – Your personal information is protected by law, including the Privacy Act 1988. Your personal information may be collected by the DVA for the delivery of government programs for war veterans, members of the Australian Defence Force, members of the Australian Federal Police and their dependants.
Go to www.dva.gov.au/privacy for more information about how DVA manages personal information. 	
RAP and other government services (such as the National Disability Insurance Scheme (NDIS), Home Care Package or Commonwealth Home Support Program (CHSP)) – Aids, appliances and modifications can be provided by RAP or other government services, such as NDIS/Home Care Package/CHSP, as long as the same aid/appliance/modification is not duplicated by both RAP and NDIS/Home Care Packages/CHSP 
 Supplier choice		  Aidacare		  Allianz Global Assistance		  BrightSky		  Country Care Group	
 
    Provider Details	

	 OT		 RN		 Physio	X	 GP/LMO	 Other (Specify Profession)		

Name:	 <UsrName>	  Provider number  (RN use AHPRA number)	 <DrProviderNo>	

Employer:	 <Practice>	  Address	  <LocationAddress>	

Phone:	 <LocationPhone>	  Fax: 	 <LocationFax>	 Mobile:	 	 Email:	<LocationEmail>	

  Client Delivery Details	

 Surname	 <PtSurname>	
		
  Given name(s)	 <PtFirstName>  <PtMidName>	

  Date of Birth	   <PtDoB>	  DVA File number	 <PtDVANo>	

Card type		 Gold		 White -  please contact DVA on 1800 550 457 or 	
				               RAPGeneralEnquiries@dva.gov.au to check eligibility 	
				               under the client’s Accepted Disability(ies).   	

 Does the client live in a Residential	No	 		
                           Aged Care Facility? 				
	 Yes		 > Please refer to the RAP in Residential Aged Care List to determine items 	
			    available to residents of aged care facilities. The list is available at https://www.dva.gov.au/providers/rehabilitation-appliances-programrap/ rap-overview#rap-items-for-our-clients-in-residential-aged-care

 Where an aged care facility is funded to provide an aid or appliance, it is expected to do so. DVA does not seek to duplicate these arrangements.

 In exceptional circumstances DVA may consider on a case-by-case basis requests for items not on the list. Please provide adequate justification with this request 	

Name:	 <PtFullName>	  DVA File number  	 <PtDVANo>	

Client Delivery Details continued

Has the client received aids,	No								
equipment and/or modifications from									
NDS, Home Care Package or CHSP?	 Yes		 >  NDIS		   Home Care Package		  CHSP		

 What aids, equipment and/or modifications have they received?	

Client's contact phone number	 <PtPhoneMob>	  Alternate contact number	 <PtPhoneH>	

 Residential Address	 <PtStreet>  <PtCity>	
	Postcode      <PtPostcode> 	
		
Delivery address		
 (If different to above)	                                                                                                      Postcode       	

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

	 Item is required for discharge	 Date of Discharge	             /       /	

  Prescription Details  (Provider to complete)	

Please refer to the RAP National Schedule of Equipment available at https://www.dva.gov.au/providers/rehabilitation-appliances-program-rap/rap-schedule

The RAP Schedule lists prior approval requirements and recommended quantity limits that should be considered in conjunction with the RAP National Guidelines for the provision of RAP items. The RAP National Guidelines are available at https://www.dva.gov.au/providers/rehabilitation-appliances-program-rap/rap-national-guidelines 	

RAP Item No.	Supplier's Product Cataalogue No.	Specifications	Quantity	

				

				

 For prior approval items, please attach clinical justification or use DVA specified forms (see RAP Schedule available at https://www.dva.gov.au/providers/rehabilitation-appliances-program-rap/rap-schedule) 	

Name:	 <PtFullName>	  DVA File number  	 <PtDVANo>	

Prescription Details continued

For White Card holders and/or prior approval items, please outline the specific clinical conditions that necessitate the supply of the item, the functional issue and how the prescribed items will address this issue. Please attach additional justification or DVA specific forms if required. 

	

	

For all home installations/modifications, please attach a completed Authority to Install/Modify form (D1323) available at https://www.dva.gov.au/providers/rehabilitation-appliances-program-rap/rap-schedule-forms 	

	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. 		

Date: <TodaysDate>	

DVA Rehabilitation Appliances Program

 Contracted Suppliers of 
Mobility & Functional Support (MFS) Equipment
 Effective 1 May 2016 

Supplier	Phone	FAX - General	Email	

Aidacare	
1300 888 052	
1300 787 052	
dva@aidacare.com.au	

Allianz Global Assistance	
1800 857 715	
1800 653 556	
mfs@allianz-assistance.com.au	

BrightSky	
1300 799 243	
1300 799 253	
mfs.orders@brightsky.com.au	

The Country Care Group	
1800 727 382	
1800 329 382	
dva@country-care.com.au	

Prescribers are reminded that the choice of supplier is theirs.
The alphabetical listing above is for administrative ease only.
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