Adult Continuous Ventilation
Equipment Request Form
This form should be used to request Continuous Ventilation equipment. Refer to the Clinical Criteria for
information regarding eligible people, eligible prescribers and equipment provided.
1. PERSON’S INFORMATION
Name
Last Name
Address
First Name
Title
Phone
Mr
Ms
Other
Suburb & Post Code
Mrs
Miss
Date of Birth
Mobile
N.B. The full technical and physician reports of all relevant tests must be submitted
with this request.
2. EQUIPMENT ELIGIBILITY
- Diagnosis – Please complete 1 or 2
1. The person is ventilator dependent for life support
Physician’s report, documenting the person’s diagnosis (chronic congenital, medical or traumatic
condition with no spontaneous respiratory effort), requiring continuous mechanical ventilation for life
support
2. The person is prescribed ventilation ≥ 16 hrs/day
2.1. Tests performed prior to and after cessation of ventilatory support demonstrating fall in SpO 2 to ≤
92% whilst awake OR
2.2. Tests demonstrating a rise in CO2 (≥ 8mmHg from baseline on paired arterial, end-tidal or
transcutaneous monitoring) when off ventilatory support OR
2.3. Physician’s report documenting signs of hypoventilation or respiratory distress which is relieved by
ventilatory support OR
2.4. Only for people with progressive disorders who are already established on bilevel ventilation; a
download or therapy compliance data demonstrating usage of equipment ≥ 16hrs/day
- Stability
3. Download of compliance data from the 1 week trial on the community appropriate ventilator
demonstrating usage of equipment ≥ 16hrs/day
4. A copy of the complete prescription settings including (but not limited to): day/night time settings,
invasive/non-invasive delivery, mode, alarms etc.
5. A copy of the oximetry or CO2 trend demonstrating that the person is medically stable on the current
community appropriate ventilator settings
- Adequacy of Current Care
6. A report documenting that an individual plan that has been communicated to all members of the
team (the person, clinical, community etc.) which meets age and disability-appropriate and physical,
emotional and social goals
7. A risk assessment in the community has been conducted and documented and the person can be
safely managed on the prescribed equipment in the community
8. The person and carer/s have acknowledged the risks and responsibility for safely managing the
person and the equipment in the community
9. A plan has been communicated to the person and their carer/s to manage clinical and equipment
emergencies
3. INTERFACE
Full face/Nasal mask
Tracheostomy
Mouth piece
4. EQUIPMENT SPECIFICATIONS
Details of the recommended community appropriate ventilator
EnableNSW Adult Continuous Ventilation Equipment Request form
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Adult Continuous Ventilation
Equipment Request Form
Please attach to this equipment request the comprehensive prescription settings for the requested ventilator,
including;
- Day/night settings (if dual settings are prescribed)
- Ventilator mode
- Alarm/s
Please contact EnableNSW for prescription pro-forma templates if required.
The person uses other respiratory equipment.
Please specify
N.B. electrical humidification, circuits and ventilation consumables can be requested through the ‘Adult
Suction Units, Electrical Humidification and Respiratory Consumables’ equipment request form.
5. DELIVERY INFORMATION
Person’s Home address
Other: Name of contact
Address
Postcode
Phone
6. PRESCRIBER DECLARATION
I declare that I have assessed the person and recommend this equipment for the safe management of this
person’s long term respiratory condition in the community.
Prescriber name
Provider number
Name of service
Qualification/Role
Address
Date
Phone
Signature
Email
Fax
7. OTHER CONTACTS
Name
Name
Address
Address
Phone
Phone
Email
Email
Fax
Fax
Qualification/Role
Qualification/Role
ENABLENSW CONTACT DETAILS
Email enable@health.nsw.gov.au
Post
EnableNSW
Parramatta NSW 2124
Locked Bag 5270
Phone
Fax
1800 362 253
(02) 8797 6543
NB: Please ensure all contact details and a completed consumer application form is provided.
EnableNSW Adult Continuous Ventilation Equipment Request form
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