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BrightSky - Department of Veterans' Affairs (DVA)
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Direct Order Form

RAP Mobility & Functional Support Products

Provider Hotline Number: 1300 550 457 (metro) and 1800 550 457 (country) - choose Option 1 for Aids and Appliances provided under the Rehabilitation Appliances Program (RAP).


This form is to be used for requesting items through the Rehabilitation Appliances Program. For prior approval items please attach clinical justification or use the DVA specified forms.


The provider is responsible for ensuring that the client is aware that their personal information is to be forwarded to DVA, and companies authorised by DVA to deliver products, for determining and /or providing benefits under the Veterans' Entitlements Act 1986. The information will be treated in a confidential manner. However, in certain circumstances it may be used for clinical review, audit or management purposes or disclosed to the client's local medical officer.


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´╗┐´╗┐Quantities and any additional information (eg preferred supplier):
Provider Details
Date of order
Profession:
Profession Other:
Provider Name*:
Provider Number:
Employer:
Address:
State:
Post Code:
Phone Number:*
Mobile Number
Email Address:*
   
Entitled Person/Delivery Details
Surname*:
Given Name(s)*:
Date of Birth:
DVA File Number:
Gender:

Card Type:

Does the entitled person live in a Residential Care Facility:




ACFI classification

 

 
Does the ACFI classification contain one high domain or two or more medium domain categories?


Does the entitled person receive help under the EACH package?

Entitled person's contact phone number: Alternative number
Residential Address:
State:
Post Code:

Delivery Address:
(if different to above)
State:
Post Code:
Hospital Discharge Details
Please fill out this section where equipment is related to the entitled person's discharge from hospital.
Item is required for discharge:
Item is a fixture:
Date of discharge:
   
   

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