Adult/Paediatric Suction Units and Respiratory Consumables for
Secretion Management Assistive Technology Request Form
1.
CONSUMER INFORMATION
Medicare No:
Last Name:
First Name:
Title:
Mr
Mrs
Ms
Date of birth:
Miss
Address:
Postcode:
Suburb:
Phone:
Mobile:
Reason for request (tick one):
New request
Change in prescription
N.B. Prescriptions older than 5 years will not be accepted, and an updated prescription/review will be
requested.
For repair, maintenance and replacements for existing EnableNSW consumers, please contact EnableNSW
on the number listed below.
2.
DIAGNOSIS
Primary diagnosis:
Date of Discharge from Hospital:
3.
/
/
ELIGIBILITY FOR SUCTION UNIT (for clients with upper airway bypassed)
The consumer’s upper airway is bypassed by means of surgical stoma, or artificial airway
PLUS
Consumer is unable to maintain their airway and independently clear secretions
PLUS
The consumer has trialed the device for 4 consecutive weeks, and has maintained a usage log. The trial
log must document the number of suction episodes per day, including date, time and reason for suction
episode (copy of log attached)
Health Support Services – EnableNSW June 2011
Developed in collaboration with LTCSA & ACI – Respiratory Network
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Adult/Paediatric Suction Units and Respiratory Consumables for
Secretion Management Assistive Technology Request Form
4.
ELIGIBILITY FOR SUCTION UNIT (for clients without a bypassed upper airway)
The consumer does not have a bypassed upper airway
PLUS
Consumer is unable to maintain their airway and independently clear secretions
PLUS
The consumer has trialed the device for 12 weeks, and has maintained a usage log for a minimum of 4
consecutive weeks. The trial log must document the number of suction episodes per day, including date,
time and reason for each suction episode (copy of log attached)
5.
ELIGIBILITY FOR ELECTRICAL HUMIDIFICATION DEVICES
Upper airway has been bypassed due to surgical stoma or artificial airway
PLUS
Consumer has sputum retention, plugging and secretions that require thinning
PLUS
Consumer uses invasive ventilation
6.
ELIGIBILITY FOR TRACHEOSTOMY/LARYNGECTOMY TUBES, HME’S AND ATTACHMENTS
Will the equipment be required on a permanent basis (≥ 12 months)?
Yes
No
Is there a plan for decannulation within the next 12 months?
Yes
No
For tracheostomy tubes, will the tube be changed in hospital (as an admitted inpatient)?
Yes
No
Is the client and/or their carer educated in using the recommended equipment safely and
Yes
No
Yes
No
Yes
No
Has a trial been completed?
Yes
No
Are the consumables compatible with other equipment?
Yes
No
appropriately, including, care and maintenance and troubleshooting?
Is the consumer/carer aware of supply limits through EnableNSW and has information
regarding purchase of additional supplies if required?
Are any changes anticipated that may impact on this equipment request (e.g. anticipated
size changes)? If Yes, please specify:
7.
DEVICES REQUESTED – Once only supply
Suction unit (electrical/portable) - 1 unit per consumer
Manual suction unit (for consumers < 12 months of age)
Heated humidifier (waterbath) for invasively ventilated consumers only
Health Support Services – EnableNSW June 2011
Developed in collaboration with LTCSA & ACI – Respiratory Network
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Adult/Paediatric Suction Units and Respiratory Consumables for
Secretion Management Assistive Technology Request Form
Type (as per contract):
Current ventilator:
Resuscitator – for consumers on life support ventilation only
10ml syringe for emergency cuff deflation (1 box only)
Manometer – for cuffed tracheostomy
Suction tubing (1 x 30m roll only)
8.
CONSUMABLES REQUESTED
Consumables may not be required or relevant for
Supplier and Code:
every application.
(As per contract/s
Annual Supply
where relevant)
Ventilation and Suction Consumables – recurrent supply
Circuits
Continuously ventilated (≥ 18 hours/day)
Disposable: 26/yr
Non-continuously ventilated (< 18 hours/day)
Disposable: 12/yr
Humidifier circuits for invasive ventilation
Non-humidified ventilator circuits for invasive ventilation
If using both non-humidified and humidified ventilator
circuits, the annual supply for the combination will be
arranged in discussion with EnableNSW
Humidifier chamber – for invasive ventilation only
Disposable: 26/yr
Ventilator circuit accessories e.g. catheter mount,
Disposable: 12/yr
connectors, adaptors, PEEP valve etc.
OR
Non-Disposable: 3/yr
Suction catheter
2160/yr
Closed suction systems (letter of justification
120/yr
attached)
Tracheostomy Consumables – recurrent supply
Health Support Services – EnableNSW June 2011
Developed in collaboration with LTCSA & ACI – Respiratory Network
Page 3 of 6
Adult/Paediatric Suction Units and Respiratory Consumables for
Secretion Management Assistive Technology Request Form
Heat moisture exchangers
360/yr
Tracheostomy tubes (cuffed or fenestrated tracheostomy
Adults: 12/yr
tube kit is inclusive of inner tube)
Paed: 52/yr
Additional tracheostomy inner tubes
2/yr
Tracheostomy tube securing device
Velcro tapes (neck strap)
OR
20 /yr
OR
Cotton tape
1 Roll/yr
Speaking Valves
3/yr
Laryngectomy Consumables – recurrent supply
Heat moisture exchange devices
360/yr
OR
Foam stoma covers
HME Attachment devices
Tracheostoma button
OR
1/yr
OR
Standard adhesive seals (base plates)
360/yr
Laryngectomy tubes (fenestrated or non-fenestrated)
1/yr
Laryngectomy tube/Tracheostoma button securing
device
Neck straps
OR
Neck clip kit
Health Support Services – EnableNSW June 2011
Developed in collaboration with LTCSA & ACI – Respiratory Network
12/yr
OR
1/yr
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Adult/Paediatric Suction Units and Respiratory Consumables for
Secretion Management Assistive Technology Request Form
9. PLAN FOR IMPLEMENTATION
Delivery address for equipment:
Clients home address
Other, provide details below:
Name:
Address:
Phone:
Fax:
Please ensure the client has received information outlining the following:
10.
-
follow up clinical review arrangements
-
the clients ongoing compliance with therapy responsibilities
-
contact numbers for clinical advice regarding treatment and clinical care
-
client/carer has completed a Consumer Application Form
PRESCRIBER DECLARATION
Please provide the name, address and contact details of the clinician/prescriber
Name:
Address:
Qualification/role:
Provider Number:
Phone:
Fax:
Email:
DECLARATION
I declare that I have assessed the consumer in consultation with an appropriate multidisciplinary team
and have the required qualification and level of experience to prescribe this equipment according to the
Professional Criteria for Prescribers.
Signature:
Date:
Health Support Services – EnableNSW June 2011
Developed in collaboration with LTCSA & ACI – Respiratory Network
Page 5 of 6
Adult/Paediatric Suction Units and Respiratory Consumables for
Secretion Management Assistive Technology Request Form
11.
OTHER CONTACTS
Please provide the contact details of any other relevant health professionals who will continue to be
involved with the management and monitoring of the client’s condition once in the community. The
delegated professional(s) will be included in any correspondence regarding provisions to the client.
Other Contact 1:
Name:
Address:
Qualification/role:
Provider Number:
Phone:
Fax:
Email:
Other Contact 2:
Name:
Address:
Qualification/role:
Provider Number:
Phone:
Fax:
Email:
EnableNSW contact details
Email:
enable@hss.health.nsw.gov.au
Post:
EnableNSW
Health Support Services
Locked Bag 5270
PARRAMATTA NSW 2124
Fax:
(02) 8797 6543
If you require assistance or further information to complete this form please
contact EnableNSW at 1800 ENABLE (1800 362 253).
Health Support Services – EnableNSW June 2011
Developed in collaboration with LTCSA & ACI – Respiratory Network
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