Equipment request
Date of request (DD/MM/YYYY)
1 1 /
1 2 /
2 0
1 4
Injured person’s name
M a r g a r e
t
B
Date of birth (DD/MM/YYYY)
1 /
0 3 /
1 9 7 9
Phone number
0
2
8
8
Age (years and months)
35 years and 10 months
Mobile number
8
8
7
7
7
7
Claim information
C T
Claim number
2 2 6 6 9
P
0
4
1 4
4
4
4
2
2
2
Date of accident (DD/MM/YYYY)
9
3
3
1 1 /
0 2 /
2 0
1 4
M
Insurer
N S W
o w n
PL
0
r
E
SECTION 1: INJURED PERSON’S DETAILS
SECTION 2: EQUIPMENT RECOMMENDATION
Hire
a.
✔
Purchase
SA
b. Describe cost effectiveness and other considerations relevant to recommendation for purchasing or hiring.
Purchase is recommended as the cost to purchase is less than the cost to hire until recovery (4 weeks) Hire cost below includes the
delivery and pick up fee.
c.
Equipment details
Model and/or specifications
Ezy Manual wheelchair - Model No 1234
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Supplier (include quote number)
Sydney Equipment Suppliers Quote # 25
Quantity
Cost (including GST and delivery)
Purchase
1
$600.00
Hire
$800.00
Equipment request
Claim number
Injured person’s name
22669933
Margaret Brown
SECTION 3: EQUIPMENT JUSTIFICATION
a. State the injured person’s goal that relates to this item of equipment. (Refer to rehabilitation plan or treatment request if relevant.)
Margaret will be able to mobilise at home and in the community despite being non weight bearing secondary to full leg plaster left
leg.
Refer to Rehabilitation Services/ RP#1 dated 11/12/2014.
b.
Describe the injured person’s need for this equipment. Include relevant assessment results, functional abilities, prognosis,
motivation, support, other equipment used or prescribed, and environment/s. (Refer to rehabilitation plan or treatment
request if relevant.)
Refer to Rehabilitation Services/ RP#1 dated 11/12/2014.
c. Describe the outcome of trial of the recommended equipment (if relevant).
Nil trial at home however Margaret is competent in this wheelchair in the hospital environment, has described home environment to
enable appropriate simulation and practice and will have supervision from his wife at discharge.
e.
✔
E
d. What are the potential risks for the injured person/carer/other users if this equipment is not provided?
Falls due to limited capacity to manage crutches.
How often will this equipment be used?
Continuously/multiple times each day
1 x daily
Several times weekly
1 x weekly
e
s
PL
Other (please provide details)
R
e
h
d. How long will the injured person need to use this equipment for?
6 weeks if plaster removed when anticipated. This will be determined by surgeon after review at fracture clinic in 6 weeks.
SECTION 4: SERVICE PROVIDER DETAILS
Practice name
F a n t a
ABN
2 2 - 3
s
t
3 - 4
3
o
n
i
c
4
4 - 5
5
a
b
S
e
r
v
i
c
e
s
5
SA
Practice address
J
M
Service provider name
R o b e r t
Unit number/Street number/Property number
1
Street name
S h o r
t
Suburb
S y d
e
y
Phone number
0 2 8 8 8
8
2
2
2
2
Email
r o
t
@
f
a
n
b
n
e
r
S
Best time/day to contact
Between 3-5pm Mon-Fri
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t
r
e
e
t
State
Mobile number
0 4 1 4 9
t
a
s
t
i
c
r
9
9
3
3
3
e
h
a
b
s
Fax number
0 2 8 8
e
r
v
i
c
e
Postcode
8
8
4
4
4
4
s
.
c
o m
.
a
u
Equipment request
Claim number
Injured person’s name
22669933
Margaret Brown
SECTION 5: INSURER DECISION
Approved
Declined
Partially approved
If declined or partially approved, provide reasons
Sample form developed 22 January 2015 for training purposes only.
Use in conjunction with Guide for Requesting equipment in the NSW Motor Accidents Scheme 2014.
Decision maker’s name
Phone number
Signature
Catalogue No. MAA724
Motor Accidents Authority, Level 25, 580 George Street, Sydney, NSW 2000
General phone enquiries 1300 137 131
Website maa.nsw.gov.au
SA
M
PL
© Copyright Motor Accidents Authority of NSW 1214
E
Date (DD/MM/YYYY)
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