1 - Home - EnableNSW
| New Request Amendment to Existing Request |
|1. PERSON’S INFORMATION |
|Person’s Name |Last Name |ENABLE # |
| | | |
| |First Name | |
| | | |
|Title | Mr Mrs Ms Miss Other |Date of birth: |
|Address | |
| |Suburb Postcode |
|Phone |Mobile |Email |
|Contact person |Relationship |
| |Partner Parent Relative Carer Friend |
|Phone |Mobile |Email |
|Diagnosis |
|Date of surgery: |Date of Discharge: |
| |N/A |
|2. EQUIPMENT RECOMMENDATION |
|New Product |Replacement |Product name and Code |Supplier |Supply Allocation |Cost (office use |
| |Product | | | |only) |
| | |Electrolarynx | | one per person* | |
| | | | | | |
| | |Indwelling Voice Prosthesis | | 2/year | |
| | | | | | |
| | |OR | | | |
| | |Non Indwelling Voice Prosthesis: | |6/year | |
| | | | | | |
| | |Trache-oesophageal Dilator: | | one per person* | |
| | | | | | |
| | |Gel Cap Insertion Kit: | | one pack per person* | |
| | | | | | |
| | |Gel Caps: | | one pack per person* | |
| | | | | | |
| | |Cleaning brushes/ flushing device: | | one pack per person* | |
| | | | | | |
| | |Tracheostoma/Hands Free Speech Valve Starter | | one per person* | |
| | |Kit: | | | |
| | | | | | |
| | |Justification required – see below | | | |
| | |Heat Moisture Exchangers (including foam stoma | | 365/year** | |
| | |covers): | | | |
| | | | | | |
| | |Tracheostoma Button: | | 1/year | |
| | | | | | |
| | |OR | | | |
| | |Standard Adhesive Seals: | |365/year** | |
| | | | | | |
| | |OR | | | |
| | |Non standard Adhesive Seals: | |180/year** | |
| | | | | | |
| | |Justification required – see below | | | |
| | |Laryngectomy Tube: | | 1/year | |
| | | | | | |
| | |Neck Straps: | | 12/year | |
| | | | | | |
|TOTAL COST (Office Use) |$ |
|* These items are supplied once only per person, annual allocations do not apply |
|** This is the standard annual allocation and actual quantity may vary depending on packaging |
|4. EQUIPMENT JUSTIFICATION |
|Has the surgical site stabilized? |
|Yes |
|No |
| |
|Will the equipment be required on a permanent basis (≥ 12 months)? |
|Yes |
|No |
| |
|Is the person able to use the recommended equipment safely and appropriately, including care, maintenance and emergency planning in the event of equipment |
|failure? |
|Yes |
|No |
| |
|Is the person aware of the annual allocation through EnableNSW and has information regarding purchase of additional supplies if required? |
|Yes |
|No |
| |
|Has a trial on all the requested equipment been completed? |
| |
|Yes |
|No |
| |
|If requesting increased annual allocation of indwelling voice prosthesis, and/or provision of non-standard adhesive seals, and/ or a tracheostoma/hands free |
|speech valve, please provide clinical justification to support the request. Please refer to Voice Related Devices and Respiratory Consumables Clinical |
|Criteria. |
|N/A |
| |
| |
| |
| |
| |
| |
|g) Are any changes anticipated that may impact on this equipment request? |
|(e.g. change to size/type of device) |
|No change anticipated. |
|Yes. If yes, please recommend appropriate supply schedule. |
|h) Would you like EnableNSW to place the first order of consumables on behalf of the person? |
|Yes Recommended supply in first order: 3 months 6 months |
|No |
|i) Is the person aware of and in agreement with this equipment request? |
|Yes Date agreement received: |
|No N.B. Application will only be processed with person/carer agreement. |
|i) A copy of the equipment request has been provided to the person. |
|Yes Date No If no, why? |
|k) Name and contact details of local speech pathologist (if different to prescriber): |
| OR |
|See prescriber details below |
|5. DELIVERY INFORMATION |
|a) Who should be notified when the equipment is ready to be delivered? |
|Prescriber Person/contact person |
|Other Provide contact name, relationship, phone, email |
|b) Delivery address for equipment |
|Person’s home address Other, provide details |
|c) Delivery Instructions Yes No If yes, details: |
|6. PRESCRIBER DECLARATION |
|Please provide the name, address and contact details of the prescriber |
| |
|Name: |
|Service: |
|Qualification/role: |
|Phone: |
|Email: |
|Address: |
|Days/hours available: |
| |
| |
|DECLARATION |
|I declare that I have assessed the person 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: |
| |
| |
|Supervisor name, name of service, address, phone, email: |Signature of supervisor (if practical): |
|(if required) | |
| | |
| | |
| |Qualification: |
| |Days/Hours available: |
| |Date: |
NB: Incomplete forms will delay processing of the application. Please ensure all contact details are provided.
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Name:
Date of Birth:
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