Replacement Prosthesis / Major Repair (e.g.

socket)
Title Mr Mrs Ms Miss Other Program
First Name PLS
DVA number _____________________
Last Name
NDIS number _____________________

Date of birth Medicare No _____________________

Centrelink No _____________________

Address Occupation

Suburb Postcode Identifies as Aboriginal and/or Torres Strait

Islander

Phone Mobile

Prosthetic User Acknowledgement

Do you intend or have you sought to claim compensation for your loss? Yes No
If YES, has this claim been settled? Yes No

I have sighted the list of manufacturers and my

Nominated Provider is: Signature

Albury P&O Services APC Alexandria APC Hunter APC Northmead

APC Central Coast OAPL-Sydney (ALC) Hunter P&O Services Northern Prosthetics
Innovo Prosthetics Southern Prosthetics & Southern Prosthetics & X-Tremity P & O
Orthotics Orthotics Nowra

Prescription Details Please complete one form for each prosthesis

Persons present at prescription
Clinic _____________________ Prosthetist ________________________
Physio/OT (include email if need to be included in approval updates) _____________________________

Level of amputation
___________________________ Left Right Bilateral
Weight in kg
___________________________ with prosthesis without prosthesis

Reason for Prescription

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________________
Prosthetic Requirements
Replacement limb Socket replacement Component replacement
Socket __________________________________________________
Suspension __________________________________________________
Knee/Elbow __________________________________________________
Ankle/Wrist __________________________________________________
Foot/Terminal device __________________________________________________
Other __________________________________________________
Consumables __________________________________________________

This prescription is valid for six months from date of issue. All sections must be completed before approval will be
considered. A Discretionary Form must be submitted for Non-Standard or Non-Contract items in this request.

It is the responsibility of the prescriber to forward this completed form to:

EnableNSW, Locked Bag 5270, Parramatta NSW 2124, Fax: 8797 6543 Ph: 1800 362 253 enable@health.nsw.gov.au 110920
 Name:
Supporting information & special requirements

Activity Level K0 K1 K2 K3 K4
Not required for upper extremity

Signature of Prescriber Date

Prescriber Name Prescriber Number

EnableNSW Authorisation Prosthetic Service Provider to complete blanks

This consumer is eligible for provision of service Prosthetic Service Provider:

through EnableNSW
This consumer is eligible for provision of service _____________________________
through the DVA
EnableNSW has approved Standard components Cast Date Trial Date
from Contract 980B
EnableNSW has approved Non-Standard Item Description $ ¢
components from Contract 980B as itemised
below Labour hours
EnableNSW has approved Non-Contract (Contract 172515)
components as itemised below Warranty Period 3 months

LIMB NO: __________________________

Type of Limb:

___________________________________

EnableNSW Authorisation Date

____________________ __________ Total Claim Submitted $

Non-standard Components used in this prosthesis paid

Prosthetic User Acceptance for by the prosthetic user:
I certify that I have received the limb referred to in this
prescription.

Signature of consumer Date

Signature of Provider Date

This prescription is valid for six months from date of issue. All sections must be completed before approval will be
considered. A Discretionary Form must be submitted for Non-Standard or Non-Contract items in this request.

It is the responsibility of the prescriber to forward this completed form to:

EnableNSW, Locked Bag 5270, Parramatta NSW 2124, Fax: 8797 6543 Ph: 1800 362 253 enable@health.nsw.gov.au 110920