Fillable Form 2: Travel and accommodation supplement: Isolated Patients (New South Wales)

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Form 2: Travel and accommodation supplement: Isolated Patients (New South Wales)

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Isolated Patients Travel and Accommodation
Assistance Scheme (IPTAAS)
Form 2: Travel and accommodation supplement
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 form for each different practitioner or
healthservice you travel to.
You should use this form:
y if you have previously submitted an application to this
practitioner or health service
y as a supplement to Form 1. Application for travel and
accommodation assistance if you would like to claim in
transittravel or more than one trip
y to complete your application if you received advance
travelassistance
y to complete your application if you bulk billed your
accommodation
Do not use this form if:
y this is your first application to this practitioner or health
service and/or
y your personal details have changed and/or
y you have not submitted a referral for this practitioner or
health service in the last two years
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
Applications must be submitted within 12 months of your
discharge or appointment end date.
For more information
Go to our website www.iptaas.health.nsw.gov.au or call us
on 1800 IPTAAS (1800 478 227).
Part A. Patient details
1. Patient ID (if known)
2. Your name
Given name
Surname
3. Your date of birth
D D/M M/Y Y Y Y
4. Your residential address
State Postcode
Part B. Treatment details
5. Name of specialist, allied health clinic, dentist or
prosthetist/orthotist
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)
Phone number
( )
Part C. Payment details
6. Your bank account details (if different to details
previously provided)
Account name
BSB number
Account number
7. Would you like a third party organisation to receive part
of your subsidy?
No Go to question 8
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
ABN
Phone number
( )
Supplier number (if known)
Part D. Escort details
8. Were you accompanied by an escort?
No Go to question 10
Yes Give details below
Your escort’s full name
9. Does your escort have a concession card issued by
Centrelink or DVA?
No
Yes
Page 1 of 3
Form 2: Travel and accommodation supplement Page 2 of 3
Part E. Travel and accommodation details
You need to provide invoices for travel and accommodation costs (except private vehicle travel and
private accommodation) with your application.
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.
10. If applicable, what is your air approval code?
Key for completing the table:
Travel mode:
Private vehicle – PV
Public transport – PT
Commercial air – AIR
Community transport – CT
Emergency transport – ET
Taxi – TX
People travelling:
Patient only – P
Escort only – E
Patient and escort – PE
Trip type:
One way – O
Return – R
Travel dates Travel
mode
People
travelling
Trip
type
Address Appointment
date
Hospitalisation dates
(if applicable)
Accommodation
dates (if applicable)
Bulk
bill
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Form 2: Travel and accommodation supplement Page 3 of 3
Part F. Practitioner or health service declaration
Please read before completing this question.
Question 11: 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 11: Practitioner or health service declaration is to be completed by
your treating practitioner or health service, or their authorised representative.
11. 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 B and 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 G. 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.
12. 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 11 of this form
I am required to keep evidence to prove I attended my appointment(s) 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
Travel dates Travel
mode
People
travelling
Trip
type
Address Appointment
date
Hospitalisation dates
(if applicable)
Accommodation
dates (if applicable)
Bulk
bill
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Start / /
End / /
From
To
Start date / /
End date / /
Admission / /
Discharge / /
Check in / /
Check out / /
Part E. Travel and accommodation details (cont.)
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Form 2: Travel and accommodation supplement: Isolated Patients (New South Wales)

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Completed 2 December 2021

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