IMPORTANT
Application for Exceptional Case Status
Completing this form
Use BLACK pen to complete all information on this form.
DVA cannot assess an incomplete or illegible form.
NOTE:
To assist in identifying entitled persons who may have Exceptional Case status, refer to Attachment A - Exceptional Case Process in the Procedure Manual for the provision of community nursing services - effective 1 October 2014.
Contacting the ECU
If you require assistance in completing this form, please telephone the Exceptional
Case Unit (ECU) on 1800 636 428.
Submitting the form
The preferred method is via DVA’s secure e-mail.
Please contact the ECU on: 1800 636 428 to register for this option.
About Secure e-mail:
http://www.dva.gov.au/site-help/sensitive-emails
OR
FAX the signed application to the ECU on the following number: (02) 6289 6682.
NOTE: The ECU must receive the full application and relevant attachments within
28 days of the requested commencement date of Exceptional Case status,
otherwise the commencement date of the exceptional case status may be
delayed until the next 28 day claim period.
The only other additional information required by the ECU to be submitted
with the signed application form and relevant attachments is the entitled
person’s current nursing treatment/care plan and, if relevant, the Local
Medical Officer (LMO) or General Practitioner orders/assessments.
Privacy Notice
Your personal information is protected by law, including the Privacy Act 1988. Your
personal information may be collected by the Department of Veterans’ Affairs (DVA)
for the delivery of government programs for war veterans, members of the Australian
Defence Force, members of the Australian Federal Police and their dependants.
Read more: How DVA manages personal information.
D1004 01/15 P1 of 9
PART A
1. Provider details
Community Nursing Provider Information
Provider name
Provider number
Provider site
(if applicable)
PART
B
2. Entitled person details
Entitled Person Information
DVA file number
Mr
Title
Mrs
Miss
Ms
Other
Surname
Given name(s)
Date of birth
/
/
Address
POSTCODE
Specify type of accommodation:
Private residence
Independant Living Unit (ILU)
Residential Aged Care Facility (RACF)
Optional question
Is the entitled
person of
Aboriginal or Torres
No
Strait Islander
descent?
3. Referral details
Yes
Referrer’s Provider
Number
Date of referral
/
/
4. Relevant periods
Commencement
date of relevant
From
/
/
claim period
Date Exceptional Case
Status is requested From
/
/
to commence
If Exceptional Case status will not commence on the first day of the relevant claim
period, specify the Schedule of Fees Item Number(s) that will apply prior to the
commencement of Exceptional Case Status
5. Reasons for Exceptional Case
What is the primary
reason for ECU
referral?
Status
D1004 01/15 P2 of 9
DVA file No.
PART
C
6. Medical condition(s)
Health History
Tick the condition(s) and specify the entitled person’s diagnosis
Auto-Immune
Cardiovascular
Dermatological
Wounds
Skin conditions
Endocrinological
ENT/Sensory
Gastro-Enterological
Genital-Urological
Haematological
Malignancy
Mental Health
Musculo-Skeletal
Neurological
Optical
Renal
Respiratory
7. Complete any attachment(s) if
necessary to inform decision
making regarding Exceptional
Case Status.
8. Clinical Risks
Attachment 1 (D1004A): Dementia/Short Term Memory Loss/Confusion
Attachment 2 (D1004B): Mental Health (Depression/Anxiety/Posttraumatic Stress Disorder/Alcohol and Substance Misuse)
Attachment 3 (D1004C): Palliative Care (End of LIfe/Metastatic Cancer/
Non-Malignant Palliative Care)
Attachment 4 (D1004D): Wound Care
Tick the appropriate risks that may impact on the entitled person’s condition
Alcohol/substance misuse
Social isolation
Pressure ulcer risk
Breathing difficulties/oxygen therapy
Nutrition
Anorexia
Cachexia
Bariatric
PEG
Confused
Delirium
Dementia
Urinary
IDC
Short term memory
Vague
Incontinence
Faecal
Has a Continence Assessment been completed?
SPC
No
Yes
No
Yes
Stoma
Recent falls
Has a Falls Assessment been completed?
D1004 01/15 P3 of 9
DVA file No.
PART C
HEALTH HISTORY continued..
9. ACAT/ACAS
10.Home Care Package
Has the entitled
No
person been
assessed by the
Yes
Aged Care
Assesssment Team/
Service (ACAT/
ACAS) in the last
12 months?
Is the entitled
person receiving a
Home Care
Package?
/
Date of assessment
/
Provide relevant assessment details in PART F
Specify approval type
No
What level of Home Care Package is the entitled
person receiving?
Yes
Level 1 supports people with basic care needs
Level 2 supports people with low-level care needs
Level 3 supports people with intermediate care needs
Level 4 supports people with high-level care needs
If you have ticked any of the above boxes, please state what service provision they
are receiving.
11.Medication Management
List the entitled
person’s current
medications
Please attach GP letter, Pharmacy list and Webster
pack if available.
Indicate who
administers the
medication
Self
If a Dose
Administration Aid
is used, which of
the following apply?
Prompting required
Has the entitled
person had a DVA No
Medication Review/ Yes
Home Medication
Review?
D1004 01/15 P4 of 9
Carer
Date of review
Registered Nurse
Enrolled Nurse
Administration required
/
What was the outcome?
/
DVA file No.
PART C
HEALTH HISTORY continued..
12.Specialist Services
Tick the specialist service(s) that the entitled person has been referred to and
specify the date visited.
Continence Nurse Adviser/Continence Program
/
/
Diabetes Educator
/
/
Gerontic Nurse Specialist/Geriatrician
/
/
Palliative Care Service
/
/
Stoma Therapist
/
/
Wound Management CNC/Wound Clinic
/
/
Other
/
/
13.LMO/GP
Specify how often
the entitled person
is seen by their
Local Medical
Officer/General
Practitioner
14.Other Health/Support Services
Is the entitled
No
person currently
receiving any other Yes
health/support
services (e.g. VHC,
delivered meals)?
15.Aids and Appliances/
Specify the aids
and appliances/
equipment that are
currently in place
16.Carer
Does the entitled
person have a
live-in carer?
Equipment
Specify the services
No
Yes
What is the relationship?
Note any significant factors limiting the primary
carer’s effectiveness
D1004 01/15 P5 of 9
DVA file No.
PART
D
17.Medications
Nursing Interventions
Medication administration
(any route, including central venous
device management and syringe driver)
Total visits per
week
Average minutes
per visit
Route(s) Used
18.Clinical Interventions
Tick clinical and personal care interventions required and specify the daily/weekly
frequency and average minutes of care per visit (See Procedure Manual Figure 6.2
Classification reference tools)
Total visits per
week
Average minutes
per visit
Dialysis
Bowel management including enema,
suppositories ordered by LMO/GP/
Specialist
Nephrostomy care
Wound
Catheter care/Catheter change
Gastronomy care
TPN/PEG feeds
Tracheostomy care
Oxygen/inhalation therapy
Pain/symptom monitoring
Blood glucose monitoring
Compression bandage
Other
D1004 01/15 P6 of 9
PART D
NURSING TREATMENT/CARE PLAN continued..
19.Personal Care Interventions
DVA file No.
Total visits per
week
Hygiene
Assistance with toileting
Catheter care including changing/
emptying urinary catheter bags, cleaning
catheter site
Assistance with stoma appliance
Fitting aids and appliances (e.g. splints,
callipers)
Compression stockings
Non-prescribed eye drops/ointment
Application non-prescribed skin cream or
lotion
Assist with self administration of oxygen
Assistance with self administration of
medication or prompting self medication
from Dose Administration Aids
Other Personal Care procedures - specify
intervention and frequency
20.Nursing Treatment/Care Plan
Please attach a copy of the CURRENT nursing
treatment/care plan
Attached
D1004 01/15 P7 of 9
Average minutes
per visit
DVA file No.
PART
E
21.Staff Attending Visits
Visit Information
Does the provision of nursing care to the client require:
one nurse only?
more than one worker per visit (please specify number)?
assistance by carer (spouse/family member)?
lifting device?
Reason for each additonal worker (e.g. to assist with obese client)
PART
F
Please describe the service you are providing:
Number of visits per day Average length of visit
TOTAL number of visits per week
Number of visits per week by:
RN
EN
Nursing support worker
Additional Comments
22.Additional Comments if needed
D1004 01/15 P8 of 9
DVA file No.
PART
G
Checklist and Declaration
23.Checklist
To prevent delays in processing your application, complete the following checklist:
I have completed the application form
I have attached a copy of the entitled person’s nursing treatment/care plan
I have completed and attached one or more of the following (if relevant):
Attachment 1 (D1004A): Dementia/Short Term Memory Loss/Confusion
Attachment 2 (D1004B): Mental Health (Depression/Anxiety/Posttrau-
matic Stress Disorder/Alcohol and Substance Misuse)
Attachment 3 (D1004C): Palliative Care (End of LIfe/Metastatic Cancer/
Non-Malignant Palliative Care)
Attachment 4 (D1004D): Wound Care
Application for Additional Travel for Exceptional Case Status
NOTE: If the relevant attachment(s) is not included with the application form, the
application for Exceptional Case Status will not be processed.
24.Declaration
I declare that the information I have supplied on this form and on any other
attachments is true and correct.
I am aware that there are penalties for making false statements (Procedure Manual
section 12.9 Inappropriate claiming for services).
Designation
Full name
Phone number
[
Signature
This application
must be signed by
the Registered
Nurse who has
completed the
assessment
]

Date
/
/
NOTE: If any changes occur to the information provided above, it is your
responsibility to notify DVA immediately by completing the relevant form.
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D1004 01/15 P9 of 9
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