DVA RAP MFS Direct Order Form - SuperPharmacyPlus

This form is to be used for requesting items through the Rehabilitation Appliances Program. For prior approval items (items that are not on the current approval list), please attach clinical justification or use 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 Department of Veterans' Affairs (DVA) for the delivery of government programs for war veterans, members of the Australian Defence Force, members of teh Australian Federal Police and their dependants.

Supplier Choice

Preferred Sub-Contractor

Date*

Provider Details

Profession*

Provider Name*

First NameLast Name

Provider Email*

example@example.com

Provider Number*

Provider Phone

Provider Organisation

Provider Address

Street Address

Street Address Line 2

CityState / Province

Post Code

Entitled Person / Delivery Details

Veteran's Surname*

Veteran's Given name(s)*

DVA File Number*

DVA Card Type*

! IMPORTANT INFORMATION REGARDING WHITE CARD HOLDERS !
Due to the nature of the DVA approval process for White Card Holders, there is a delay and additional process for all orders for white card holders.

Order must be approved by DVA prior to supply (Currently a 6 week wait - please notify your veteran that this may be an issue)
Orders must all have a "Clinical Justification" completed to confirm that the product should be covered under DVA listed conditions.
Any non-contracted items will require a manual quote as well (this is organised by us, please do not contact supplier or manufacturers for quotes)

Gender

Date of Birth*

Delivery Information

Entitled person's phone number*

Or phone number of person receiving delivery

Alternative contact number

Residential Address

Street Address

Street Address Line 2

CityState

Post Code

Delivery to above address

Delivery Address

Street Address

Street Address Line 2

SuburbState

Post code

Special Delivery Instructions

Hospital discharge details (if applicable)

Date of discharge (if applicable)

Aged Care Facility Information

Does the entitled person live in a Residential Aged Care Facility?

Does the ACFI Classification contain one high domain or two more medium domain categories

Does the entitled person receive help under Home Care Package Level 4 (formerly EACH)

Product Details

Most Popular DVA Products

	Quantity Requested
Crutch - Forearm - AP03-6160 Adult 6161 Adult Tall (Specify size and weight in comments)
Crutch - Underarm - AP03- CR21747L Adult Tall CR1747M Adult (Specify size and weight in comments)
Knee Scooter - AP07-CR1792
Seat Walker / Rollator 6" - AP12-RM201R-6
Seat Walker / Rollator 8" - AP12-HF0320
X-Frame Walker - AP12-57042 Standard
Bath Board - AZ01-CR1577
Bath Transfer Bench - AZ01-RM425
Shower Stool - AZ04-RM403
Shower Chair - AZ04-RM402
Over Toilet Aid - BE06-RM400
Toilet Surround - BE06-1900
Bedside Commode - BE02-BE0020
HiLite Chair - AC01-RM533
Utility Chair - AC01-RM535
Over Bed Table - AB13-VG832A
EzyAs Plastic Frame - AU13-SM261
EzyAs Handle AU-13-SM262
Reacher (60/76/90cm) - AH11-VM901
Pedal Exerciser - AV02-M3500
Leg Lifter AP09-CR2048
Omron Premium Blood Pressure Monitor - HEM7121
Omron Premium Blood Pressure Monitor - HEM7280T

I wish to prescribe products which are not able to be found on the approved schedule

I am prescribing compression garments

Prescribing Compression Garments:
In order to enable us to process your order quickly and efficiently, we ask that you please provide all the relevant product details for any compression garment (as applicable)

- Compression Class (15-20, 20-30, 30-40)

- Compression Garment Length (Knee, Thigh, Chaps, Waist, Glove, ArmSleeve, ArmSleeve with Gauntlet, Leg, Footpiece, Knee Piece, Thigh Piece)

- Material / Style (For Jobst this includes: Relief, UltraSheer, ForMen Casual, Active, Farrow Wrap)

- Size (Small, Medium, Large, Extra Large; Size I-VIII gloves)

- Specific Length (Regular, Long - Gloves / Elvarex2 / Farrow Wrap)

- Toe option (Open Toe / Closed Toe - dependant upon material and options)

- Colour (Beige default if unspecified as black unavailable in many fabric styles)

For a full prescribing form for Jobst products, please see Jobst Prescription Pad

Alternatively, you can specify a product code from either our website or Jobst Code Chart

Product Information (Off-contract / non-approved items)

Please note that some delay may be inevitable as DVA assesses non-approved products

Please see approved list of products DVA Schedule Approved Products

Prescribed Product 1

Item Number | DVA Supplier Number | Description (where known)

Prescribed Product 2

Item Number | DVA Supplier Number | Description (where known)

Clinical Justification (White Card Holders)

Attachments

Please attached documents such as clinical justification

Take Photo (add image to application)

Additional Comments?

Weight / Height of veteran or other specifics for consideration

Signature of therapist