Fillable MASS 20 DLA/MOB Daily Living Aids and Mobility (Queensland Health)

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MASS 20 DLA/MOB Daily Living Aids and Mobility (Queensland Health)

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The MASS 20 DLA/MOB Daily Living Aids and Mobility (Queensland Health) form is 20 pages long and contains:

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  • 55 check-boxes
  • 514 other fields

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File type: PDF

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Page 1 of 13
DO NOT WRITE IN THIS BINDING MARGIN
© The State of Queensland (Queensland Health) 2021
V 6.01 11/2021
SW8006
Medical Aids Subsidy
Scheme (MASS) Queensland
Health
MASS 20 DLA/MOB
Daily Living Aids and Mobility
Equipment
(Affix identification label here)
Family name:
Given name(s):
Date of birth: Gender:
☐M ☐F ☐ I
MASS Service Centre Details
Website: health.qld.gov.au/mass/
T
elephone: 07 3136 3524
Brisbane:
PO Box 281, Cannon Hill Qld 4170
MASS-Equipment@health.qld.gov.au
Townsville:
PO Box 980, Hyde Park Qld 4812
MASS-Equipment-TSV@health.qld.gov.au
MASS-eApply is the preferred method for prescribers to submit applications. More information can be found on
health.qld.gov.au/mass/mass-online-applications
.
Privacy Statement
The Queensland Health, Medical Aids Subsidy Scheme (MASS) collects administrative, demographic and clinical
data as part of the MASS application processes, in accordance with the Information Privacy Act 2009 and Hospital
and Health Boards Act 2011, in order to assess your eligibility for funding assistance for the supply of aids and
equipment.
The information will only be accessed by Queensland Health officers. Some of this information may be given to the
applicant’s carer or guardian; other government departments who provide associated services; the prescribing
health professional for further clinical management purposes; and to those parties (e.g. commercial suppliers,
community care and repairers) requiring the information for the purpose of providing aids, equipment and services.
Your information will not be given to any other person or organisation, except where required by law.
Part A – To be completed by the applicant / carer
Applicant’s Personal Details
1 Name
Family name
Given name(s)
Previ ous
2 Date of birth
3 Gender
☐ Male ☐ Female ☐ Intersex or Other
4 Address details
Permanent residential address
Suburb / town
Postcode
Delivery address ☐ Same as residential address
Suburb / town
Postcode
Postal address ☐ Same as delivery address
Suburb / town
Postcode
5 Contact Numbers I consent to receive communication regarding this application through SMS ☐ Yes ☐ No
Home
Mobile
Other
6 Does the applicant identify with Aboriginal or Torres Strait Islander descent?
☐ Aboriginal
☐ Torres Strait Islander
☐ Both
☐ Neither
7 Country of Birth
☐
Australia
☐
Other
8 Language spoken at home
☐
English
☐
Other
9 Does the applicant receive Commonwealth Home Support Programme (CHSP) services?
☐ No ☐ Yes, tick type of CHSP services below:
☐ Domestic Assistance
☐ Centre based respite
☐ In home respite
☐ Personal Care
☐
Therapy Support Services
☐
Other e.g. Allied Health:
Specify
10 Is the applicant receiving a Home Care Package?
☐ No ☐ Yes, specify level:
NOTE:
if the applicant will be receiving a Home Care Package or CDC
High Care Package at hospital discharge, you should mark ‘Yes’.
☐ Level 1
☐ Level 2
☐ Level 3
☐ Level 4
11 Is the applicant a resident in a Commonwealth funded care facility?
☐
No
☐
Yes, A
CFI Score of L (Low), M (Medium) or H (High) for:
ADL
Behaviour
Complex Care
Page 2 of 13
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Medical Aids Subsidy Scheme
(MASS) Queensland Health
MASS 20 DLA/MOB
Daily Living Aids and Mobility
Equipment
(Affix identification label here)
Family name:
Given name(s):
Date of birth:
G
ender:
☐M ☐F ☐ I
Applicants Personal Details (Continued)
12 Does the applicant receive other assistance? (e.g. NDIS, NIISQ, Palliative Care Services, Transition Care)
☐ No ☐ Yes - type of assistance:
Name
Transition Care - Discharge Date
13 Concession Eligibility Card
☐ Queensland Government Seniors Card
☐
Centrelink Pensioner Concession Card
☐
Centrelink Health Care Card
☐ Department of Veterans’ Affairs Card
Card Number
NOTE: To confirm eligibility, please provide a copy of both sides of your
eligibility card
OR for Centrelink/Department of Veterans’ Affairs Card
Holders:
a completed MASS 84 Proxy Access to Centrelink Information
Carer or Alternative Contact Person Details
14 Name
Family name
Given name(s)
15 Relationship to Applicant
16 Does the applicant consent for MASS to contact this person ☐ No ☐ Yes
17 ☐ Primary / Preferred Contact ☐ Alternative Contact
18 Contact Information
Telephone
Mobile
Email
19 Postal Address ☐Same as applicant
Suburb / town
Postcode
Compensation or Insurance Claims
20 Does a WorkCover, third party, public risk or any other form of compensation or insurance claim
apply for injuries for which assistance from MASS, Queensland Health is requested?
☐ No
☐ Yes, please complete the details below:
I ☐ have / ☐ have not engaged a legal representative to act on my behalf regarding a claim for damages.
Solicitor’s name
Firm’s name
Firm’s address
Suburb / town
Postcode
Telephone
Fax
Email
• I undertake to repay MASS the cost of assistance provided to me by MASS, should I obtain damages
for injuries from any past, present or future claim/s.
• I undertake to advise MASS of the progress of my claim for damages. This may be in the form of written
communication to MASS from my legal representative.
• I provide authority for MASS to write to and provide information to my legal representative named above.
• This authority remains valid until revoked by me in writing.
Signature of Applicant/Guardian or authorised decision-maker on behalf of applicant
Name of Applicant/Guardian or authorised decision-maker on behalf of applicant
Date
Signature of Witness
Name of Witness
Date
click to sign
signature
click to edit
click to sign
signature
click to edit
Page 3 of 13
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Medical Aids Subsidy
Scheme (MASS) Queensland
Health
MASS 20 DLA/MOB
Daily Living Aids and Mobility
Equipment
(Affix identification label here)
Family name:
Given name(s):
Date of birth:
G
ender:
☐M ☐F ☐ I
Consent to Email Communication
MASS offers applicants the opportunity to communicate by email. This page provides information about the risks
of email, conditions for use of email communication and how email communication is used. It will also be used to
document your consent to communicate with you by email.
Risks of communicating via Email
Communication by email has a number of risks which include, but are not limited to, the following:
a MASS cannot guarantee that any particular email will be read or responded to.
b An email can be circulated, forwarded and stored in paper and electronic files.
c Backup copies of emails may exist even after the sender or the recipient has deleted their copy.
d Email senders can easily misaddress an email or email can be received by unintended recipients.
e Email communication can be intercepted, altered, forwarded or used without authorisation or detection.
f Employers and online services have a right to archive and inspect communication transmitted through their
systems.
Conditions for the use of electronic communication
a MASS will use reasonable means to protect the security and confidentiality of information sent and received.
However, because of the risks outlined above, MASS cannot guarantee the security and confidentiality of
email communication, and MASS will not be liable for the inadvertent disclosure of confidential information.
b Email is not appropriate for urgent or emergency situations, nor is it a substitute for care that may be
provided during a face-to-face visit or a telephone/telehealth consultation.
c It is my responsibility to inform MASS of email address changes
d When emailing MASS, I will:
i Put the applicant name, date of birth and MASS reference number (URN) in the body of the email, not
the subject line.
ii Include the general topic of the email in the subject line. For example, “application status” or “delivery”
iii Contact MASS via the alternative communication methods (phone, letter etc) if a reply is not received
within a reasonable period of time.
e I will not use email for communication regarding sensitive medication information.
f I am responsible for informing MASS of any types of information that I do not want to be sent by email.
g I am responsible for protecting my password or other means of access to email. MASS is not liable for
breaches of confidentiality caused by myself or any third party.
Collection Notice
a Queensland Health (QH) is required to manage my personal information in accordance with the Information
Privacy Act 2009 and the Hospital and Health Boards Act 2011.
b Email communication between myself and the health care professional will be printed and filed in my client
record. As emails are a part of the client record, other individuals authorised to access the client record will
have access to those emails.
c Email messages from myself may also be delegated to another health care professional or staff member for
response. Administration staff may also receive and read or respond to my emails.
d Some of my personal information on my medical record may be given to caregivers, guardians and other
government departments who provide associated services that require my information for the purpose of
providing a health care service
21 I consent to receiving communication by email regarding this application and the delivery of MASS
services ☐ Yes ☐ No
22 I consent to receiving communication by email regarding MASS Service improvement activities.
Service improvement activities include surveys, invitations to MASS education sessions workshops and/or
webinars, MASS events or newsletters. ☐ Yes ☐ No
23 Email Address
You can withdraw your consent to email communication by contacting MASS.
There will be no impact on service provision should you choose to withdraw consent.
Page 4 of 13
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Medical Aids Subsidy Scheme
(MASS) Queensland Health
MASS 20 DLA/MOB
Daily Living Aids and Mobility
Equipment
(Affix identification label here)
Family name:
Given name(s):
Date of birth:
G
ender:
☐M ☐F ☐ I
Applicant Acknowledgements
I confirm that:
a I have actively participated in the assessment and trial of aid/s and associated modifications and accessories.
b The features and options of the aid/s, and any appropriate alternatives have been fully explained to me by
my prescribing health professional.
c The possible cost implications that I may incur as a result of MASS policy or subsidy funding have been
explained to me by my prescribing health professional.
d The aid/s prescribed are suitable for my needs.
e I have a safety switch/residual current device installed in my home (only applicable for MASS subsidy funded
mobility and daily living aids that require charging/operation through mains power).
I acknowledge that the aid/s provided by MASS are on permanent loan and:
a Remain the property of MASS, unless advised by MASS in writing.
b Will only be used by me for the purposes prescribed.
c Will be maintained by me on a weekly/monthly basis as outlined in the information provided to me with the aid.
d Must be returned to MASS when I no longer require its use or it is replaced, unless advised by MASS in writing.
e Must not have any repairs and/or modifications carried out without specific prior approval by the local MASS
service centre i.e. Brisbane or Townsville.
f MASS takes no responsibility for any injury sustained by me through use of the aid subsidy funded/allocated
by MASS.
g Could be allocated from existing MASS stock. MASS may choose to reallocate suitable equipment and not
purchase new.
h Unless the equipment supplied to me with written notification that it has been tested for electrical safety and
that the equipment was found to be electrically safe, I should assume that it has not been tested and where
the assumption applies, Queensland Health makes no warranty as to the electrical safety of the equipment.
I agree to:
a Having photographs/video footage taken to assist with my application (for power wheelchairs, optional for
other aids). Refer to MASS 82 Consent to Photograph/Video form.
b Answer promptly any enquiries made from time to time by MASS service centre as to the condition of the
aids and my continued need for its safe and effective use.
c Notify my local Queensland Health Community Health Centre or local MASS service centre should I cease to
be able to use the aid/s safely and effectively.
d Use the aid/s within the conditions of MASS.
e Inform MASS within 14 days of any change in my contact details, residential address, or eligibility for MASS
subsidy funding assistance. For example:
• No longer eligible for a healthcare card.
• In receipt for a Home Care Package Level 3 or 4.
• In receipt of a Consumer Directed Care (CDC) package level 3 or 4.
• Admission to high care residential facility etc.
I understand that if I have taken ownership of a MASS subsidised aid that:
a Repairs and maintenance become my responsibility.
b Insurance cover becomes my responsibility.
24 I agree to accept the conditions stated above ☐ Yes ☐ No
25 I acknowledge that my information listed in this application is current and correct ☐ Yes ☐ No
26 I consent to MASS contacting via email: other government departments who provide associated
services; the prescribing health professional for further clinical management purposes; and to those
parties (e.g. commercial suppliers, community care and repairers) requiring the information for the
purpose of providing aids, equipment and services. ☐ Yes ☐ No
27 Signature of Applicant/Guardian or authorised decision-maker on behalf of applicant
Signature
Name
Date
If authorised decision-maker, specify authority e.g. Power of Attorney, Carer, Parent/Guardian, Support Person
A copy of these acknowledgements can be found on the applicant information sheet available on our website
on: health.qld.gov.au/mass/prescribe/living and health.qld.gov.au/mass/prescribe/mobility
click to sign
signature
click to edit
Page 5 of 13
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Medical Aids Subsidy Scheme
(MASS) Queensland Health
MASS 20 DLA/MOB
Daily Living Aids and Mobility
Equipment
(Affix identification label here)
Family name:
Given name(s):
Date of birth:
G
ender:
☐M ☐F ☐ I
Part B – Prescriber Assessment Complete for MASS funding Consideration
Functional Assessment
1 Applicant’s permanent disability that necessitates the assistive equipment
2 Provide other relevant information, functional changes and/or comorbidities
3 What are the applicant’s measurements?
Height
cm
Weight
kg
4 Describe the applicant’s functional status and ability in the following areas:
Mobility
☐
Walks Independently
☐
Walks with Assistance:
☐ Minimum
☐ Moderate
☐ Maximum
☐
Walks with Aid:
☐
Single point stick
☐
Wheeled walking aid
☐
Other
☐
Manual Wheelchair Self Propelled
☐
Manual Wheelchair Carer Assist:
☐ Minimum
☐ Moderate
☐ Maximum
☐
Power Wheelchair
Balance:
☐ Functional
☐ Decreased
☐ Non-Functional
Weight Bearing Status:
☐ Full
☐ Partial
☐ Non
Transfers
☐
Independent
☐
Independent with aids or set up:
☐
Walker/frame
☐
Slideboard
☐
Grab rails
☐
Other
☐
Assistance:
☐ Minimum
☐ Moderate
☐ Maximum
☐
Dependent
Transfer Method:
☐ Slide/Side
☐ Stand/pivot
☐ Step
☐ Hoist
☐ Upper limb weight bearing
☐
Other
Provide additional information specific to endurance/frequency if relevant
Upper limb function
☐
Decreased Strength
☐ Shoulder
☐ Elbow
☐ Wrist
☐ Hand
☐
Decreased range of movement:
☐ Shoulder
☐ Elbow
☐ Wrist
☐ Hand
☐
Tone:
☐ Low
☐ High
☐ Spasms
☐ Fluctuating
☐
Hand Function:
☐ Functional
☐ Decreased
☐ Non-Functional
Lower limb function
☐
Decreased Strength:
☐ Hip
☐ Knee
☐ Ankle
☐ Foot
☐
Decreased range of movement:
☐ Hip
☐ Knee
☐ Ankle
☐ Foot
☐
Tone:
☐ Low
☐ High
☐ Spasms
☐ Fluctuating
Postural control in sitting:
☐ Full
☐ Limited
☐ Nil Functional
Skeletal deformity:
☐ Scoliosis
☐ Kyphosis
☐ Pelvic Tilt
☐ Pelvic Rotation
☐ Pelvic Obliquity
☐
Upper Limb
☐
Lower Limb
☐
Other
5 Describe the applicant’s living situation (e.g. lives alone, receives carer support etc):
☐ Alone
☐ Alone with informal support
☐ Alone with formal support
☐
With family/carer
☐
Other
Page 6 of 13
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Medical Aids Subsidy Scheme
(MASS) Queensland Health
MASS 20 DLA/MOB
Daily Living Aids and Mobility
Equipment
(Affix identification label here)
Family name:
Given name(s):
Date of birth:
G
ender:
☐M ☐F ☐ I
Part C – Equipment Application Complete for MASS funding consideration
Use this form to apply for:
• Multiple items for an individual or
• Any single item excluding wheeled walking aid, equipment modifications, static or 3-in-
1
c
ommode, bath transfer bench, non-standard Bathboard or similar purpose device.
1. If applying for modifications to an existing MASS item on permanent loan, use Daily Living and Mobility
Equipment Letter Template.
2. If replacing a current MASS item with the same item i.e. like with like – replacing same size, brand a
nd
mode
l of sling, use Daily Living and Mobility Equipment Letter Template
3. If applying for a Static or 3-in-1 Commode, Bath Transfer Bench, Swivel Bathseat, Bath Lift or similar
purpose device or Non-standard Bathboard only use the
MASS 20 BTA Application for Static 3-in-1
Commode/Transfer Bench/Swivel Bathseat/Bath lift or similar purpose device/Non-standard Bathboard. .
4. If applying for a Wheeled Walking Aid only through MASS – use the MASS 20 WWA Application for Wheeled
Walking Aid.
Current versions of these forms can be found on the MASS website: health.qld.gov.au/mass
Equipment – Request
1 Item/s Requested
☐ Static or 3-in-1 Commode.
☐ Bath Transfer Bench/Swivel Bathseat/Bath Hoist or non-standard Bathboard, or similar purpose device.
☐
Mobile Shower Commode (MSC) or Shower Trolley.
☐ Patient Lifting Device (Hoist) and Sling or Patient Transfer Platform
☐ Pressure Redistribution Mattress/Overlay or Sleep Positioning System
☐
Wheeled Walking Aid (WWA)
☐ Manual Wheelchair (MWC)
☐ Tilt-in-Space Manual Wheelchair (including specialised stroller)
☐
Power Wheelchair (PWC)
☐ Pressure Redistribution Cushion
☐ Back up manual wheelchair
☐
Modifications to existing equipment – please list item/s requiring modifications:
2 Is this equipment required for discharge from hospital, transition care or post-acute services?
☐ Yes ☐ No
3
a) Has the applicant had one or more falls in the past month? ☐ Yes ☐ No
b) Is the aim of the requested item to prevent future falls? ☐ Yes ☐ No
4
a) Does the applicant have a current pressure injury? ☐ Yes ☐ No
b) Is the aim of the requested item to manage a current pressure injury? ☐ Yes ☐ No
5 Why does the current equipment need replacing?
☐ Not applicable
☐ No longer meets applicant needs (Provide reason)
☐ MASS requested replacement
☐ Beyond economic repair (Describe condition of equipment)
Page 7 of 13
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Medical Aids Subsidy Scheme
(MASS) Queensland Health
MASS 20 DLA/MOB
Daily Living Aids and Mobility
Equipment
(Affix identification label here)
Family name:
Given name(s):
Date of birth:
G
ender:
☐M ☐F ☐ I
Equipment Trials and Justification
6 All item/s Trialled
Model / Type / Size Length and location of Trial Results and Comments
7 Item/s selected: Provide details of requested equipment, including cushion if applicable
Model / Type / Size Trial supplier
8 Does your client require Tilt in Space? ☐ Yes ☐ No
If yes, please select all that apply:
☐
Facilitate repositioning, transfers, and weight shift
during the operation of the Power Wheelchair
☐
Facilitate optimal positioning for comfort and
function due to deformity/pain/involuntary
movement/ abnormal tone/seizure activity
☐
Achieve or maintain a suitable posture
☐
Redistribute pressure so less pressure is directed
through bony prominences on the seat
☐
Facilitate hoist transfers
☐
Facilitate the client’s negotiation over uneven
surfaces, kerbs, ramps etc.
☐
Better manage gastrointestinal function
☐
Better manage respiration
☐
Facilitate the client’s operation of a power
wheelchair
Page 8 of 13
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Medical Aids Subsidy Scheme
(MASS) Queensland Health
MASS 20 DLA/MOB
Daily Living Aids and Mobility
Equipment
(Affix identification label here)
Family name:
Given name(s):
Date of birth: Gender:
☐M ☐F ☐ I
Equipment Trials and Justification Continued…
For Daily Living Aids or Mobility Aids, provide justification for modifications/accessories if applicable below.
9 Modification/Accessories (As listed on supplier’s quote)
Modification/Accessory Clinical Justification to support MASS funding
10 Has the prescribed equipment been successfully trialled in the home environment?
☐ Yes ☐ No
If no, describe how you have determined the equipment will be suitable for the applicant at home
11 Can the prescribed equipment be appropriately used, maintained and stored by the applicant or
carer? ☐ Yes ☐ No
12 Has a safety switch/residual current device been installed for items connected to mains power for
operating/charging? ☐ Yes ☐ No ☐ Not Applicable
13 Upon allocation of MASS stock equipment, please indicate how the applicant would prefer to receive
the user manual for the equipment:
☐ Paper
☐ USB
☐ Disc
☐ Email – please ensure the email address is provided in Part A of this form
14 Is the equipment requested on the MASS SOA Product List? ☐ Yes ☐ No
If no, explain why a non-SOA item has been requested:
Equipment Prescription
For ALL MASS applications, complete questions 15 to 20
If applying for Pressure Redistribution Equipment go to Question 15
If applying for Sleep Positioning Systems go to Question 16
If applying for Sleep Positioning System go to Question 17
If applying for a Patient Transfer Platform go to Question 18
If applying for a Hoist and Sling go to Question 19
If applying for a Sling and Attachment go to Question 20
If applying for a Bathing and Toileting Aids go to Question 21
If applying for
Mobility Aids (Wheelchair or Wheeled Walking Aid)
go to Question 22
Page 9 of 13
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Medical Aids Subsidy Scheme
(MASS) Queensland Health
MASS 20 DLA/MOB
Daily Living Aids and Mobility
Equipment
(Affix identification label here)
Family name:
Given name(s):
Date of birth:
G
ender:
☐M ☐F ☐ I
Equipment Prescription Continued…
For Pressure Redistribution Equipment
15
a) Please select one or more of the following which apply:
☐ At risk of developing a pressure injury as identified through a formal screening tool
☐ unable to effectively redistribute pressure
☐ History of pressure injury
☐ Major fixed skeletal deformity and/or motor/sensory loss with the potential for pressure injury
development
☐ Confined to bed for prolonged periods of time and is at risk of developing pressure injury
b) Have skin checks been completed to confirm suitability? ☐ Yes ☐ No
If no, describe why skin checks were not completed
For Non-Basic Pressure Redistribution Mattress
16
a) Does the applicant have a significant history of pressure injury? ☐ Yes ☐ No
If yes, provide details
b) Does the applicant have severe restriction in mobility? ☐ Yes ☐ No
If yes, provide details
c) Has an extensive range of basic pressure redistribution mattresses been trialled/ considered?
☐ Yes ☐ No
If yes, provide details
For Sleep Positioning Systems
17 Does the applicant require support and positioning in lying to facilitate (please select all that apply)?
☐ Improved respiration and/or swallowing
☐ Prevention of pressure injury through specific positioning needs
☐
Improved positioning for prevention of contractures and/or deformities
For a Patient Transfer Platform
18
a) Can the applicant effectively reposition their feet to complete a pivot or similar transfer?
☐ Yes ☐ No
b) Does the device requested provide adequate support to allow the applicant to stand?
☐ Yes ☐ No
c) Is the applicant able to adequately stand with the support provided by the device?
☐
Yes
☐
No
Page 10 of 13
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Equipment Medical Aids
Subsidy Scheme (MASS)
Queensland Health
MASS 20 DLA/MOB
Daily Living Aids and Mobility
Equipment
(Affix identification label here)
Family name:
Given name(s):
Date of birth:
G
ender:
☐M ☐F ☐ I
Equipment Prescription Continued…
For a Hoist and Sling
19
a) For a Standing Hoist
i. Does the applicant require mechanical assistance to stand? ☐ Yes ☐ No
ii. Does the applicant demonstrate reliable ability to assist with the standing action being facilitated by the
hoist? ☐ Yes ☐ No
b) For a Mobile Floor Hoist
i. Can the applicant effectively complete a standing or non-standing transfer with assistance or a device
such as a slide board? ☐ Yes ☐ No
ii. Does the applicant require a non-basic hoist for increased lift height, leg spread or boom length?
☐ Yes ☐ No
If yes, provide details
c) For a Ceiling Hoist
i. Can the applicant effectively complete a standing or non-standing transfer with assistance or a device
such as a slide board? ☐ Yes ☐ No
ii. Have you completed and attached the MASS 27 Ceiling Hoist Checklist? ☐ Yes ☐ No
d) For a Multilift Hoist
i. Can the applicant effectively complete a standing or non-standing transfer with assistance or a device
such as a slide board? ☐ Yes ☐ No
NB: one or more of the following criteria must apply:
ii. Does the applicant require support both standing and full lift for different transfer purposes?
☐ Yes ☐ No
iii. Is the applicant able to complete stand transfer with assistance of a standing hoist but will experience
predicted decline in function? ☐ Yes ☐ No
iv. Does the applicant’s needs fluctuate between transfer methods? ☐ Yes ☐ No
v. Has the full lift component of the multilift hoist been considered for current and likely future needs?
☐
Yes
☐
No
For a Sling and Attachment
20
a) Is the prescribed mobile floor hoist, standing hoist or ceiling hoist compatible with the prescribed
sling? ☐ Yes ☐ No
If no, please complete and submit MASS 25 Hoist and Sling Compatibility Checklist
b) Is the basic hoist attachment (standard spreader bar) suitable? ☐ Yes ☐ No
If no, specify attachment and provide justification ☐ 4 Point ☐ Pivot ☐ Other:
Page 11 of 13
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Medical Aids Subsidy Scheme
(MASS) Queensland Health
MASS 20 DLA/MOB
Daily Living Aids and Mobility
Equipment
(Affix identification label here)
Family name:
Given name(s):
Date of birth: Gender:
☐M ☐F ☐ I
Equipment Prescription Continued…
For Bathing and Toileting Aids
21
a) Can the applicant effectively walk and/or transfer to the toilet and/or shower in the home?
☐ Yes ☐ No
b) Can the applicant walk or transfer to a static commode? ☐ Yes ☐ No
c) For a Mobile Shower Commode/Shower Trolley
i. Is there sufficient space in the bathroom or wet area for a mobile shower commode/shower trolley
including over toilet access if applicable? ☐ Yes ☐ No
ii. Can the applicant or carer propel the chair/trolley, including changes in floor level?
☐ Yes ☐ No
d) For a Mobile Shower Commode with Height Modified Frame - Have adjustable height mobile
shower commodes been trialled/considered and found unsuitable? ☐ Yes ☐ No
Provide details
For Mobility Aids
22
a) Can the applicant independently or effectively use an aid to walk within the home environment?
☐ Yes ☐ No
b) For a Manual Wheelchair
i. Is a wheelchair required to provide the primary means of functional mobility in the home environment?
☐ Yes ☐ No
ii. Is the applicant a long duration independent user? ☐ Yes ☐ No
iii. Does the applicant require a non-standard size and/or options to meet their positioning and postural
needs? ☐ Yes ☐ No
For the Non-Basic MWC Subsidy, what are the needs that cannot be met with a basic MWC Subsidy?
c) For a Power Wheelchair
i. Have you completed and attached the MASS 24 Home Access Checklist? ☐ Yes ☐ No
ii. Can the applicant self-propel a manual wheelchair effectively in their home environment?
☐ Yes ☐ No
iii. Can the applicant effectively control and manoeuvre the requested PWC inside the home and around
any other areas to be accessed by the applicant? ☐ Yes ☐ No
iv. If no, during the assessment have they demonstrated the ability to acquire skills to effectively operate
the power wheelchair? ☐ Yes ☐ No
v. Have you considered your client’s hearing, vision, cognition and ability to control the chair?
☐ Yes ☐ No
Provide details:
d) For a Specialised Stroller - Is the applicant under 5 years of age? ☐ Yes ☐ No
Provide details why the child is unable to be effectively positioned in a non-specialised stroller or use a manual or
powered wheelchair
Page 12 of 13
DO NOT WRITE IN THIS BINDING MARGIN
Equipment Medical Aids
Subsidy Scheme (MASS)
Queensland Health
MASS 20 DLA/MOB
Daily Living Aids and Mobility
Equipment
(Affix identification label here)
Family name:
Given name(s):
Date of birth:
G
ender:
☐M ☐F ☐ I
Prescriber Details to be completed in full for all applications
First Prescriber
1 Name
Family name
Given name(s)
2 Profession
3 Current Registration?
☐ Yes ☐ No
4 Organisation Details
Organisation name
Branch
Address
Suburb / town
Postcode
5 Contact Details
Telephone
Mobile
Fax
Email
Contact days
Contact hours
6 Signature and Date
I certify that the information contained in this application is in accordance with the MASS General Guidelines
Signature
Date
Second Prescriber
7 Name
Family name
Given name(s)
8 Profession
9 Current Registration?
☐ Yes ☐ No
10 Contact Details
Telephone
Mobile
Fax
Email
Contact days
Contact hours
11 Please list equipment you have prescribed
12 Signature and Date
I certify that the information contained in this application is in accordance with the MASS General Guidelines
Signature
Date
Prescriber Checklist
13 Have you:
☐
Provided an accurate quote/s, accurate specification form (where relevant) and full clinical justification
for the prescribed equipment?
☐
Provided additional supporting documentation if required e.g. hoist and sling compatibility checklist
and/or pressure risk assessment?
☐
Provided a Home Access Checklist for the prescribed power wheelchair?
☐
Retained a copy of the full application for your reference?
☐
Provided a signed MASS 84 Proxy Access to Centrelink Information form or photocopy of both sides of
the applicant’s concession card?
Page 13 of 13
DO NOT WRITE IN THIS BINDING MARGIN
Medical Aids Subsidy Scheme
(MASS) Queensland Health
MASS 20
Equipment Services Co-Payment
Acknowledgement
(Affix identification label here)
Family name:
Given name(s):
Date of birth: Gender:
☐M ☐F ☐ I
Equipment Category
Estimated Co-Payment
Please refer to the relevant Equipment Guidelines for subsidy levels
Wheeled Walking Aid
Bedside/3 in 1Static Commode
Transfer Bench or Bath Seat
Hoist and/or slings or Transfer Platform
Pressure Redistribution Mattress/Overlay
Mobile Shower Commode
Manual or Power Wheelchair and Modifications
Pressure Redistribution Cushion
Modifications
Client Declaration
I declare:
• My prescribing therapist has made me aware of the relevant MASS Guidelines, subsidy levels and Client
Acknowledgement prior to signing the application;
• My prescribing therapist has answered all questions in this application in consultation with myself;
• The possible cost implications that I may incur as a result of MASS policy or subsidy funding, as per the above
estimated co-payment, have been explained to me by my prescribing health professional;
• I agree to make payment of the co-payment to the supplier within 3 weeks of the date of letter approving my
application. If I do not make payment within this timeframe, I understand my application will be cancelled.
Signature of Client/Guardian or authorised decision-maker on behalf of client
Name of Client/Guardian or authorised decision-maker on behalf of client
Date
If authorised decision-maker, specify authority e.g. Power of Attorney, Carer, Parent/Guardian, Support Person
Therapist/Prescriber Declaration
I declare:
• I have notified my client of their responsibilities when applying for subsidy funding through MASS, as per
the relevant MASS Guidelines and Application Acknowledgement form;
• I have advised the client of the subsidy levels applicable to the equipment requested in the application;
• I have notified my client of the possible cost implications that may be incurred as a result of MASS policy
or subsidy funding, as per the estimated co-payment above;
• I have notified my client that if the co-payment is not paid to the supplier within 3 weeks of the date of the
approval letter, the application will be cancelled.
Prescriber Name
Organisation
Signature
Date
Page 15 of 15
DO NOT WRITE IN THIS BINDING MARGIN
Medical Aids Subsidy Scheme
(MASS) Queensland Health
MASS 84
Proxy Access to Centrelink
Information
Non-standard Bathboard
(Affix identification label here)
Family name:
Given name(s):
Date of birth: Gender: ☐M ☐F ☐ I
This form is used for applicants to provide consent to Medical Aids Subsidy Scheme (MASS) staff to use Centrelink
Confirmation eServices (CCeS) to verify eligibility. This consent will be used for the sole purpose of authorising
Centrelink to provide information to MASS to determine your eligibility in relation to assistance or services provided
by MASS.
This form can be completed by the concession card holder (the customer), or their customer representative. A
customer representative is a person who is authorised by the customer, or by law, to represent the customer or
manage the customer’s affairs. Customer representatives can include nominees, authorised representatives and
powers of attorney.
MASS staff, in accordance with the MASS Privacy Statement, are committed to maintain strict confidentiality in all
aspects of service delivery. You are assured that this information will remain confidential. Your information will not
be divulged without your consent, except where required by law.
Please provide the following Commonwealth benefit card information, which must be in the name
of the adult card holder/applicant. Child applicants will be required to provide a copy of their card.
Concession Card Type
☐ Centrelink Health Care Card
☐ Centrelink Pensioner Concession Card
☐ Department of Veterans’ Affairs Card
CRN / Concession Card Number
Issue Date on Card
Name of Card Holder
Expiry Date on Card
Address on Card
I, _________________________________________________________________________ authorise:
• The Medical Aids Subsidy Scheme (MASS) to use Centrelink Confirmation eServices to perform a
Centrelink/DVA enquiry of my Centrelink or Department of Veterans’ Affairs customer details and
concession card status to enable the business to determine if I qualify for a concession, rebate or
service.
• Services Australia (the agency) to provide the results of that enquiry to MASS.
I understand that:
• The agency will disclose personal information to MASS including my name, date of birth, address, state,
concession card type and status to confirm my eligibility for MASS services (subsidy funding assistance
for assistive technology, aids and/or consumable products).
• This consent, once signed, remains valid while I am a customer of MASS unless I withdraw it by
contacting the MASS or the agency. I can get proof of my circumstances/details from the agency and
provide it to MASS so my eligibility for MASS services can be determined.
• If I withdraw consent or do not alternatively provide proof of my circumstances/details, I may not be
eligible for the service provided by MASS.
Signed
Date
Signed by☐ the card holder OR ☐ a customer representative on behalf of the card holder (complete below)
Name
Representative Type (e.g. Power of Attorney):
Please attach copy evidence to confirm authority e.g. copy of Enduring Power of Attorney to this form.
Email OR Post completed form to a MASS Service Centre
Email: MASS184@health.qld.gov.au
Website: health.qld.gov.au/mass
Brisbane:
PO Box 281, Cannon Hill Qld 4170
Telephone: 07 3136 3636
Townsville:
PO Box 980, Hyde Park Qld 4812
Telephone: 07 4433 8000
Office Use Only
Details and eligibility Confirmed: ☐ Yes ☐ No
Date: / /
MASS Officer
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MASS 20 DLAMOB Daily Living Aids and Mobility (Queensland Health)

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Completed 4 May 2022

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