Fillable Form 1: Application for travel and: Isolated Patients (New South Wales)

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Form 1: Application for travel and: Isolated Patients (New South Wales)

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Isolated Patients Travel and Accommodation
Assistance Scheme (IPTAAS)
Form 1: Application for travel and
accommodationassistance
Page 1 of 4
Use our online services
You can apply online. This means you do not have to complete
thispaper form. You can register to use our online services at
iptaas.enable.health.nsw.gov.au
When to use this form
You require a separate application for each different practitioner or
health service you travel to.
You should use this form if:
y this is the first time you have applied for assistance from IPTAAS
to travel to this practitioner or health service
y you have not submitted a referral for this practitioner or health
service in the last two years
y your personal details have changed since the last time you
submitted an application and you have not updated them using
our online services
What else you may need to provide
We may require documentation to support your application. You
may need to provide:
y invoices for travel and accommodation costs
y evidence that you have attended your appointment
Filling in this form
y please use black or blue pen
y print in BLOCK LETTERS
y mark boxes like this
with a or
y where you see a box like this Go to question… skip to
the question number shown. You do not need to answer the
questions in between.
For more information
Go to our website www.iptaas.health.nsw.gov.au or call us on
1800 IPTAAS (1800 478 227).
Applications must be submitted within 12 months of your discharge or appointment end date.
Part A. Eligibility details
Please read before answering question 1.
Patients receiving financial assistance for travel and accommodation from other services are not eligible for IPTAAS. If you are receiving
assistance from another government or third party service do not complete this form.
1. Have you received, or are you eligible for financial assistance for travel and accommodation from
An Australian federal, state or territory government travel scheme, other than IPTAAS?
No Yes
Department of veterans’ affairs?
No Yes
Workers compensation?
No Yes
Motor vehicle insurance?
No Yes
Part B. Patient details
2. Patient ID (if known)
3. Your name Title Given name Middle name Surname
4. Your date of birth
D D/M M/Y Y Y Y
5. Your gender Male Female Other
6. Your Medicare card number
Line no.
7. Do you have a concession card issued by Centrelink or DVA?
No Go to question 8
Yes Give details Concession card number Concession card expiry date
D D/M M/Y Y Y Y
8. Your residential address
State Postcode
9. Your postal address
(if different to residential)
State Postcode
10. Your contact details Email Phone number Mobile number
( )
What is your preferred contact method? Post Email Phone Mobile
11. Are you of Aboriginal or Torres Strait Islander Australian descent?
No Yes
12. Your authorised contact Name Relationship to you
(optional)
Phone number Mobile number
( )
Form 1: Application for travel and accommodationassistance Page 2 of 4
Part C. Referral details
Please read before completing Part C. Referral details.
Part C: Referral details is only required if this is the first time you have applied for assistance from IPTAAS to travel to this practitioner or
health service, or you have not submitted a referral to this practitioner or health service in the last two years.
If required, Part C: Referral details is to be completed by your referring practitioner or their authorised representative.
13. Referring practitioner details Full name Phone number
( )
14. Treatment details Name of practitioner or health service you referred the patient to
Treatment location Type of treatment referred for
Is the practitioner or health service the nearest to the patient’s residence?
Yes Go to question 15
No Give details below
Why was the patient not referred to the nearest practitioner or health service?
15. Referring practitioner declaration (to be completed by the referring practitioner or their authorised representative)
Name Position
I declare that:
y the information provided in Part C of this form is complete and correct
I understand that:
y giving false or misleading information is an offence
Signature
Date
D D/M M/Y Y Y Y
Part D. Air travel details
Please read before answering question 16.
If you need to travel by commercial air, you should get an air approval. Your practitioner or their authorised representative must contact
IPTAAS to get an air approval. You will only get an air approval if you meet the air approval criteria.
16. What is your air approval code?
Part E. Treatment details
17. What type of treatment did you travel for? (Select one and answer applicable questions)
Specialist
Was your treatment part of a clinical trial?
No Yes
Was your travel for health screening?
No Yes
Allied Health
Dental
Do you have a cleft palate?
No Yes
Did you have surgery under general anesthesia?
No Yes
Prosthetic/Orthotic
Did you travel to a public hospital or public clinic?
No Yes
Form 1: Application for travel and accommodationassistance Page 3 of 4
18. Treatment details Name of specialist, allied health clinic, dentist or prosthetist/orthotist Phone number
( )
Medicare provider number (not applicable to allied health or prosthetic/orthotic treatment)
OPTIONAL: AHPRA registration number (if known) (not applicable to allied health or prosthetic/orthotic treatment)
Treatment address
State Postcode
19. Were you hospitalised?
Yes Give details Admission date Discharge date
D D/M M/Y Y Y Y
D D/M M/Y Y Y Y
No If no, what was your appointment date? Start date End date (if different to start)
D D/M M/Y Y Y Y
D D/M M/Y Y Y Y
20. Did you need to stay before or after the hospitalisation or appointment dates?
No Go to question 21
Yes Give details nights before and/or nights after
Please read before completing question 21.
Question 21: Practitioner or health service declaration is optional unless you are staying more than two nights before or after
your appointment/hospitalisation dates.
If completed, Question 21: Practitioner or health service declaration is to be completed by your treating practitioner or health
service, or their authorised representative.
21. Practitioner or health service declaration (to be completed by the treating practitioner, health service or their authorised
representative)
Name Position
I declare that:
y the information provided in Part E of this form is complete and correct
I understand that:
y giving false or misleading information is an offence
Signature
Date
D D/M M/Y Y Y Y
Part F. Payment details
22. Your bank account details
Account name
BSB number Account number
23. Would you like a third party organisation to receive part of your subsidy?
No Go to question 24
Yes Give details below
What part of your subsidy would you like the third party organisation to receive?
Travel Accommodation Both
Third party organisation details
Name Phone number
( )
ABN Supplier number (if known)
Form 1: Application for travel and accommodationassistance Page 4 of 4
Part G. Travel and accommodation details
Please read before completing Part G. Travel and accommodation details.
This form is for one trip from your residence to the health service and return. If you would like to claim in transit travel or travel and/
or accommodation for more than one trip you should complete and attach Form 2. Travel and accommodation supplement to this
application.
You need to provide invoices for travel and accommodation costs (except private vehicle travel and private accommodation) with your
application.
24. Were you accompanied by an escort during travel or accommodation?
No Go to question 26
Yes Give details Your escort’s full name
25. Does your escort have a concession card issued by Centrelink or DVA?
No Go to question 26
Yes Give details Your escort’s concession card number Your escort’s concession card expiry date
D D/M M/Y Y Y Y
26. Your travel details
Travel dates Departure date
D D/M M/Y Y Y Y
Return date
D D/M M/Y Y Y Y
Mode of travel (Check applicable box) Forward Patient Escort Return Patient Escort
Private vehicle
Public transport
Commercial air
Community transport
Emergency transport
Taxi
27. Are you claiming accommodation?
No Go to question 29
Yes Give details Check in date
D D/M M/Y Y Y Y
Check out date
D D/M M/Y Y Y Y
28. What type of accommodation did you stay in?
More information about accommodation types is available on our website.
Private For Profit Not for profit
Part H. Patient declaration and privacy
The information contained in this application is protected by law from unauthorised access and misuse. The information will only be
accessed by health service staff directly involved in providing services to the applicant, or with other lawful excuse. You can view our
privacy statement on our website.
29. Patient declaration (to be completed by you or your parent, guardian, escort or authorised contact)
I declare that:
y The information I have provided in this form is complete and correct and the documents provided are genuine
y If applicable, I am authorised to complete this application on behalf of the patient
I understand that:
y NSW Health may make relevant enquiries to assess this application and make sure I receive the correct subsidy
y I may be audited. If my practitioner or health service did not complete question 21 of this form I am required to keep evidence to
prove I attended my appointment for two years
y Giving false or misleading information is an offence
Your name
Your signature Date
D D/M M/Y Y Y Y
Submitting your form
Check that all required questions are answered and that the form is signed and dated. You can submit this form and supporting
documentation to your local IPTAAS office by email, post or fax. Please ensure forms submitted by post are addressed to IPTAAS.
Hunter New England – Tamworth
Post: Locked Bag 9783, Tamworth NEMSC NSW 2348
Email: HNELHD-IPTAAS@health.nsw.gov.au
Fax: (02) 6766 4576
Northern NSW, Mid North Coast – Port Macquarie
Post: PO Box 126, Port Macquarie NSW 2444
Email: MNCLHD-TFH-IPTAAS@health.nsw.gov.au
Fax:
Far West – Broken Hill
Post: PO Box 457, Broken Hill NSW 2880
Email: FWLHD-IPTAAS@health.nsw.gov.au
Fax: (08) 8080 1695
All other
Post: Locked Bag 5270, Parramatta NSW 2124
Email: IPTAAS@health.nsw.gov.au
(02) 5524 2996
You may be able to provide your form in person at one of our offices. Contact IPTAAS for more information about over the counter services.
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Form 1: Application for travel and: Isolated Patients (New South Wales)

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Completed 12 July 2021

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