Type of benefit
Date
Patient's Signature
Centrelink benefit number Expiry date
Patient
Type of benefit
Date
Escort's Signature
Centrelink benefit number Expiry date
Escort
1.4 CONCESSION DETAILS AND CENTRELINK CONSENT continued
1.7 BULK BILL ACCOMMODATION DETAILS (if applicable)
Email addressPhone number Fax number
Contact person
Name of accommodation provider
Patient/Guardian
Date
Signature of Patient/Guardian
I have read and understood the terms of this bulk billing conditional
approval and agree to meet all accommodation costs if I do not
comply with the above conditions.
Date
Signature of Accommodation Provider
Accommodation Provider
I have read and understood the terms of this bulk billing conditional
approval. I understand that it is the responsibility of the accomm-
odation provider to seek payment of the accommodation costs from
the claimant and therefore should assist the patient/claimant to
complete the bulk billing application form where possible.
TERMS AND CONDITIONS
• The patient must meet the eligibility criteria for IPTAAS.
• It is the responsibility of the accommodation provider to organise payment directly with the patient for any additional costs incurred
outside of the IPTAAS guidelines
• Before the patient leaves the accommodation facility, Parts 2 and 3 of the IPTAAS Claim form is required, along with an accommodation
invoice and any other claimable receipts.
• Invoices must include the conditional approval number, along with both the patient & escort name. Failure to do this may lead to non-
payment of your invoice
• Any additional fees (e.g. late check-out) are subject to approval by IPTAAS.
Note: A personal contribution of $30 will be deducted from the total benefits payable for each return journey or weekly subsidy if claiming
under the 200km per week cumulative distance criterion (not applicable to pensioners and Health Care Card holders). Contributions will
be capped at four co payments each financial year. In cases where a personal contribution cannot be deducted from the claimant's travel
entitlement the contribution is deducted from the accommodation entitlement and payment arrangements must be made between the
service provider and the patient. No benefit is payable when the patient is on leave during the course of their treatment.
AUTHORISATION
Page 2 of 5
Patient name Date of birth
1.6 THIRD PARTY PAYMENT DETAILS – Required if payment is to be made to a separate organisation
Organisation name Phone number
Vendor number (if known)
Specify amount to be paid
Which portion of the claim would you like paid to another organisation?
Accommodation
Travel $
Give details of the bank account you want your IPTAAS payments made to. Reimbursements will be made by Electronic Funds Transfer
(EFT). If the details provided are incorrect, your payment will be delayed.
1.5 BANK ACCOUNT DETAILS FOR CLAIM PAYMENT
Should any part of this reimbursement be paid to another organisation or charity?
Yes
No
BSB number Account number Email address for payment notice (if different to that provided in 1.2)
Name of bank, building society or credit union
Account name
If sending by post, a signature is required.
A signature is not required if the form is sent by email
and the email signature includes patient/carer details.
If sending by post, a signature is required.
A signature is not required if the form is sent by email
and the email signature includes patient/carer details.
If sending by post, a signature is required.
A signature is not required if the form is sent by email
and the email signature includes patient/carer details.
If sending by post, a signature is required.
A signature is not required if the form is sent by email
and the email signature includes patient/carer details.
