AHP Equipment Request Form

AHP Equipment Request Form
Client Details

Clients WILL be registered with MND Queensland and we must have client details and signed consent to process loans, however there is no obligation to be a Member of MND Queensland.
Client Name*

First NameLast Name
Client Phone Number*

Area CodePhone Number
Client Email
We Require either a client email address or Next of Kin Email Address
Client Diagnosis*
E.g. MND or ALS, PBP, PMA, PLS
Client DOB*
Client Communication *
Delivery Address*

Street Address

Street Address Line 2

SuburbState / Province

Postcode
Access to Property Concerns (e.g Steep Driveway)
Delivery Contact*

Client (details as above)Other
Delivery Contact Name*

First NameLast Name
Relationship to Client
Delivery Contact Phone*

Area CodePhone Number
Delivery Contact Email
We Require either a client email address of Next of Kin Email Address
Funding Details
Funding Source*

NDIS FundedNDIS Eligible/Application PendingMy Aged Care FundedSelf FundedNo-cost Equipment Scheme: For individuals with MND not receiving government funding or fully using their My Aged Care packages. Please provide details on your funding status to access this no-cost charitable equipment support.Other
Support Coordinator's Name (if applicable)

First NameLast Name
Support Coordinator's Company
Support Coordinator's Email
example@example.com
Support Coordinator's Phone Number

Area CodePhone Number
NDIS Number*
This is found on any letter received from NDIS
NDIS Plan Start Date*

MonthDayYear
Date
NDIS Plan End Date*

MonthDayYear
Date
Assistive Technology (AT) Maintenance, Repair & Rental Budget Availability*

YesNo
Management Type*

Plan-managedSelf-managedNDIA Managed
Plan Manager's Name*

First NameLast Name
Plan Manager's Company
Plan Manager's Email*
example@example.com
Plan Manager's Phone Number*

Area CodePhone Number
Email for invoicing*
example@example.com
Current approved My Aged Care level (even if not currently receiving this level)*

Commonwealth Home Support ProgrammeLevel 1 Home Care PackageLevel 2 Home care PackageLevel 3 Home Care PackageLevel 4 Home Care PackageResidential Aged Care Placement
Name of Home Care Package Organisation*
Coordinator's Name
Home Care Provider Email Address*
Home Care Provider Contact Number*
MAC Reference number
Free Equipment Scheme
MND Queensland is a charitable organisation dedicated to ensuring that all Queenslanders impacted by MND have access to best practice care and support. This includes ensuring that vital equipment is available to those who need it. Many Queenslanders can use existing forms of funding, such as a My Aged Care - Home Care Package to pay the hire costs for MND Queensland to provide equipment. However, we are aware that some people impacted by MND do not yet have any funding or are in a position where the funding they have is inadequate to meet the cost of equipment hire, as it is needed for other important services such as in-home care. In these instances, MND Queensland will cover thecost of hire thanks to the generosity of our donors. Due to the fact that we receive no ongoing government funding and have an ethical responsibility to ensure that our donor dollars are used wisely, please complete below to confirm your eligibility for your equipment hire costs to be waived.

Eligibility will be confirmed with the client and/or their case manager/MND Advisor.
The client has a confirmed diagnosis of MND*

Yes
The reason for the client applying is:*

They are fully utilising their MY Aged Care - Home Care Package funding for other vital servicesThey have applied for NDIS and waiting for my first Plan to commence (at which time MND Queensland will commence claiming the usual weekly hire fee as per NDIS guidelines)They are waiting for approval of a My Aged Care - Home Care PackageOther
If Other - please specify*
Referring Allied Health Professional

Please fill your details below.
Name*

First NameLast Name
Occupation *
Company Name*
Referring AHP Email*
example@example.com
Office Phone Number*

Area CodePhone Number
Contact Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Work Hours
Equipment Required

Please Select Equipment Required *

	Select All Required	Please Indicate Size W x L (Inches)
Mobile Shower Commode
Mobile Shower Commode Tilt In Space
Shower Chair
Toilet Seat Raiser
Electric Bed and Foam Mattress (Single size)
Electric Bed and Foam Mattress (King single size)
Alternating Air Mattress
Repose Overlay
Hoist with Sling (Sling size and type Yoke/Pivot)
EyeGaze
Recliner (Single Motor)
Recliner (Dual Motor)
Regency Chair
4 Wheel Walker
Pressure Cushion
Manual Wheelchair
Power Wheelchair
Cough Assist Machine
Portable Suction Unit
NeuroNode + IPad
Recliner (Quad Motor)
Other (Please Detail Below)
EyeGaze Stand (by itself)
Manual Wheelchair (Tilt in Space)
Trilogy
OBI Feeder

Please let us know if there are special requirements (eg special attachments) *
Please indicate stand attachment for EyeGaze if selected.
By completing this request I agree:
- To provide training and support in the use of this equipment to the client and any other persons who need to be familiarised with its use and operation.
- I acknowledge that this equipment is from an equipment library, may not be new, and is provided to best meet the needs of the client.
- The equipment is not to be modified in any way without written agreement from MND Queensland, as stated in the MND Queensland Equipment Service Loan Agreement.
- Please confirm the client has consented to you sharing their information with MND Queensland and is aware that this will result in an electronic client record being created in their name on our client database for the purpose of retaining information necessary for the provision of services relevant to their care needs.
Please Sign to Complete Referral*

Clear
Please note: This request will be given a registration number for future reference and a copy returned to you within 7 days indicating the availability of items requested. Your client will also receive acknowledgement in writing of this request. Our equipment team hours are Monday - Thursday 08:30am - 4:00pm Should you require a faster response, please contact our office directly on (07)3372 9004.
Should be Empty:

AHP Equipment Request Form

Client Details

Funding Details

Free Equipment Scheme

Referring Allied Health Professional

Equipment Required