CHSP minor - Home Assist Community Services

Minor Modifications CHSP, DVA, Private

To be completed by Occupational Therapists for minor modification requests.

“If you are requesting a service for a HOME CARE PACKAGE CONSUMER and YOU ARE NOT THE PACKAGE PROVIDER Please DO NOT COMPLETE this referral form – Your request for service MUST GO DIRECTLY TO THE HCP PROVIDER FOR APPROVAL in the first instance. Please send all of your relevant documentation to the provider for approval, once this has been reviewed the provider will submit this REFERRAL form and attach any PURCHASE ORDER/SERVICE REQUEST documentation as required to provide your consumer with a service as requested.

Form Reference Number 0

Does the Person have a Home Care Package? *

Name of Home Care Package Provider

Email Address of Provider

Case Managers Details

Aged Care Number of Consumer

Occupational Therapist's Name *

Occupational Therapist's Organisation *

Occupational Therapist Email Address *

Phone Number *

Mobile

Title *

First Name *

Surname *

Preferred Name

Email Address

Date of birth *

Street Address *

City *

ZIP / Postal Code

Postal Address (if different)

City

ZIP / Postal Code

Phone Number *

Mobile

Please select the appropriate funding category *

Please note to be eligible for CHSP Home Modifications funding clients need to be registered and have a My Aged Care Referral Code for Home Modifications. Please advise client to contact My Aged Care if they do not have a Home Modifications Referral Code and contact Home Assist Community Services on (07) 4123 2234 with their Code so we can assist them with CHSP funding and avoid delays.

Is the consumer registered with My Aged Care? *

Aged Care User ID *

Referral Code for Home Modifications *

Living Arrangements *

Disability Indicator *

ATSI Status *

Department of Veteran Affairs *

Pension Type *

Pension Number

Medicare Number

Any material costs are paid by the client, the labour is supplied at no cost to the client. Client is aware they will need to pay for material costs. *Yes

All work requested and completed should comply where possible with the relevant Australian and New Zealand Standards. If this request falls outside the standards, clinical justification will be taken as priority by the referrer signing below.

Priority rating for completion of work

Work Requested

Diagrams / Drawings / Photos attached

All work requested has been discussed with and has the consent of the client and/or their carer.

Occupational Therapist's Signature

Additional details or advisements (if required)

File Upload

For Uploads over 8MB, please use one of the free of charge file transfer services for example https://wetransfer.com/

Additional Contact Person

Relationship to Client

Phone

Mobile

Consent to act on behalf of recipient

Residency Type *

Owner / Landlord / Agency Name (if applicable)

Owner / Landlord / Agency Postal Address

Suburb and Postcode

Phone

Mobile

E-Mail

Dwelling Details *

Country of Birth

Language

Diagnosis/Medical Condition

Discharge Date (if applicable)

Priority rating for completion of work *

Work Requested *

Diagrams / Drawings / Photos Attached *

For Uploads over 8MB, please use one of the free of charge file transfer services for example https://wetransfer.com/

All work requested has been discussed with and has the consent of the client and/or their carer. *Yes

Additional Details

Please send a copy of this form submission to

Occupational Therapist's Signature *

Submission Date *

133 Adelaide Street Maryborough 07/4123 2234

07 4123 2234

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Minor Modifications CHSP, DVA, Private

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Home Assist Community Services

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Non-Profit Organisation Established in 1999 - QBCC Builders Registration: 1109355 ABN: 82493405845
Home Assist Community Services 133 Adelaide Street Maryborough QLD4650 - Phone 07/4123 2234 Monday to Friday 9am until 3pm (message bank after hours)

07 4123 2234

Login

Minor Modifications CHSP, DVA, Private

Call Us Now 07 4123 2234

Apply For Support

I need Help finding a form

Home Assist Community Services

- Work For Us -

Non-Profit Organisation Established in 1999 - QBCC Builders Registration: 1109355 ABN: 82493405845 Home Assist Community Services 133 Adelaide Street Maryborough QLD4650 - Phone 07/4123 2234 Monday to Friday 9am until 3pm (message bank after hours)

Non-Profit Organisation Established in 1999 - QBCC Builders Registration: 1109355 ABN: 82493405845
Home Assist Community Services 133 Adelaide Street Maryborough QLD4650 - Phone 07/4123 2234 Monday to Friday 9am until 3pm (message bank after hours)