EnableNSW provides assistive technology and services to eligible NSW residents with a chronic medical condition or permanent/long term disability.

Please select which program/s you are applying for:

Aids & Equipment Program (including Equipment Allocation Program (EAP), Home Enteral Nutrition (HEN),

Continence)

Specialised Equipment Essential for Discharge (SEED) program

Home Respiratory Program, comprising:

Home Oxygen Service (HOS)

Children’s Home Ventilation Program (CHVP)

Adult Home Ventilation Program (AHVP)

Continuous Positive Airway Pressure (CPAP)

Prosthetic Limb Service (PLS)

INSTRUCTIONS

An Application Form needs to be completed by the applicant or their representative when requesting assistance from EnableNSW. This form should also be completed when updating details and/or at least every two (2) years. EnableNSW may request an updated form at any time to ensure information is current and correct.

In addition to this Application Form, an Equipment Request Form is required and must be completed by an eligible prescriber. The Equipment Request Form provides information regarding the assessment process and reasons for recommendation of the assistive technology.

This form provides the applicant’s demographic information and details of their medical condition/ disability for the purpose of determining eligibility.

Incomplete forms will delay the processing time, please ensure you compete all relevant sections and provide any of the applicable documentation below

Checklist:

all sections completed (page 1-8)

section 1 signed by representative (if applicable)

copy of Medicare card attached

copy of Visa or letter from Immigration (if applicable)

copy of Centrelink Pension card attached and/or your partners (if applicable)

copy of permanent residency visa (if applicable)

copy of Australian Taxation Office assessment notice attached and/or your partners (if applicable)

declaration in section 7 signed by the applicant or their representative

Equipment Request Form completed by an eligible prescriber is also required

For further information or assistance:

Telephone: 1800 ENABLE (1800 362 253)

Email: HSNSW-enable@health.nsw.gov.au

Website: www.enable.health.nsw.gov.au

Applicant Agreement
Are you completing this form on behalf of the applicant? Yes No (skip to question 2) Do you have the applicant’s agreement to complete this form on their behalf? Yes Please note, This form will not be accepted if you do not have the applicant’s permission. Also, completing this section does not make you an authorised contact person for the applicant.
Your Family Name:	Your Given Name:
Relationship:	Telephone:	Mobile:
Your Signature: Date of completion: E.g. dd-mm-yyyy

Personal Details
Title:	Mr	Mrs	Other:
Miss	Ms
Family Name:	Given Name:
Date of Birth: E.g. dd-mm-yyyy	Female Male Other ►
Permanent Residential Address:
Suburb/Town:	Postcode:
Postal Address (if different from above)
Medicare No:	Line no:	Expiry: E.g. dd-mm-yyyy
Please provide a copy of your Medicare card
Telephone: Mobile: Updates via SMS? Yes No	Email: Updates via email? Yes No
Preferred contact method:	Home phone Mobile phone	Email Postal mail
Do you have a disability that is permanent or long-term? Yes No
Diagnosis/Medical Condition: Where possible, please provide date of diagnosis and/or cause of injury:

Applicant’s Full Name:	DOB: E.g. dd-mm-yyyy

Are you of Aboriginal or Torres Strait Islander origin?	Aboriginal Both Aboriginal and Torres Strait Islander	Torres Strait Islander Neither
What is your country of birth? Are you a permanent resident of NSW (Australian Citizen or holder of permanent residency visa) Yes (if yes, please skip to next question) No (If no, please complete section below) What is your Visa status? Visa name: Visa subclass: Length of Visa: Please provide a copy of your Visa or letter from Immigration
Do you need an interpreter when dealing with EnableNSW? This includes an interpreter for people who have a communication or hearing impairment. No Yes ► Please provide details

Alternative contact person (This will allow them to contact EnableNSW and enquire on your behalf)
Title:	Family Name:	Given name:
Address:
Suburb/Town:	Postcode:
Mobile:	Telephone:
Relationship:	Email:
Alternative contact person (additional)
Title:	Family Name:	Given name:
Address:
Suburb/Town:	Postcode:
Mobile:	Telephone:
Relationship:	Email:

Applicant’s Full Name:	DOB: E.g. dd-mm-yyyy

Type of Residence
Is your usual address:
Private home or rental (including Housing NSW, independent living unit in retirement village)	Yes No
Group Home operated by a Non-Government Organisation	Yes No
Large Residential Centre (greater than 8 residents) operated by a Non-Government Organisation If ‘yes’, please provide name of the facility	Yes No
Residential Aged Care Facility (includes nursing home or hostel) If ‘yes’, please provide name of the facility	Yes No
Hospital or Temporary/Respite Care Facility Name of hospital/facility Date of discharge E.g. dd-mm-yyyy Return to usual address, OR Change of usual address, please provide details below:
Other If you are not residing at your usual address, please provide details of your current living arrangements below:

This space has deliberately been left blank

Applicant’s Full Name:	DOB: E.g. dd-mm-yyyy

Other Assistance
To assess your eligibility, EnableNSW requires information about any other government funded programs that you are waiting on, in receipt of or have received. Please note, if you are eligible for or receiving assistance from the following programs the level of assistance we provide may be adjusted. Please ensure you tick all boxes, including ‘no’ where applicable:
Australian Government Aged Care Home Care Package: Waiting on the national queue for package 1, 2, 3, 4 In receipt of package level 1, 2, 3, 4 If you have accepted a lower package while waiting a higher package, please tick both options	Yes No
Transitional Aged Care Package (TACP)	Yes No
Commonwealth Home Support Program (formerly HACC)	Yes No
Continuity of Support Program (COS) (ADHC/FACS packages formerly known as AIDAS, High Needs Pool, Individualised Funding Package)	Yes No
Lifetime Care and Support Authority (LTCSA) (may be known as ICare)	Yes No
Dust Diseases Board (may be known as ICare)	Yes No
Continence Aids Payment Scheme (CAPS)	Yes No
Department of Veterans Affairs (DVA) If yes, please confirm: Card colour: Gold White Orange Card number:	Yes No
National Disability Insurance Scheme (NDIS) If yes, please confirm: NDIS number Start date E.g. dd-mm-yyyy	Yes No

Question 5 continued next page

Applicant’s Full Name:	DOB: E.g. dd-mm-yyyy

WorkCover, Compulsory Third Party or other insurance scheme: If yes, please provide details:	Yes No
Will you be seeking compensation relating to your disability/injury? Have you received compensation relating to your disability/injury? Please note, people who have received compensation or damages in respect of the condition/disability for which equipment/services are required are ineligible for EnableNSW. Exceptions will be reviewed on a case by case basis.	Yes No Yes No

Financial eligibility (complete relevant sections)
If you are completing this form for a person under 16 years of age you do not need to provide information relating to income. Please proceed to question 7.
Customer Confirmation I authorise: • EnableNSW to use Centrelink Confirmation eServices to perform a Centrelink/DVA enquiry of my Centrelink or Department of Veterans’ Affairs Customer details and concession card status in order to enable the business to determine if I qualify for a concession, rebate or service. • The Australian Government Department of Human Services to provide the results of that enquiry to EnableNSW. I understand that: • The department will use information I have provided to EnableNSW to confirm my eligibility for EnableNSW programs and services and will disclose to EnableNSW personal information including my name, address, payment and concession card type and status. • This consent, once signed, remains valid while I am a customer of EnableNSW unless I withdraw it by contacting EnableNSW or the department. • I can obtain proof of my circumstances/details from the department and provide it to EnableNSW so that my eligibility for EnableNSW programs and services can be determined. • If I withdraw my consent or do not alternatively provide proof of my circumstances/details, I may not be eligible for programs and services provided by EnableNSW. Details about the Centrelink Confirmation eServices are available on Centrelink’s website. Do you authorise EnableNSW to confirm the current status of your Commonwealth Benefit and other details as they pertain to your concessional entitlement? Yes No (if no, please attach a photocopy of your pension card) If yes, please provide: Pension Type: Pension Card Number: Not applicable: Signature: Date of completion: E.g. dd-mm-yyyy

Applicant’s Full Name:	DOB: E.g. dd-mm-yyyy

Income Details: Are you in receipt of other income? If yes, please attach a copy of your Australian Taxation Office Assessment Notice from the most recent financial year:	Yes No
Partners Income Details:
Do you have a spouse/partner (opposite/same-sex)?	Yes No
Is your spouse/partner in receipt of a pension? If yes, Pension Type: Pension Card Number: Please attach a copy of your spouse’s/partner’s pension card.	Yes No
Is your spouse/partner in receipt of other income? If yes, please attach a copy of your spouse’s/partner’s Australian Taxation Office Assessment Notice from the most recent financial year.	Yes No
Dependants: Do you have any dependants? If yes, how many?	Yes No

This space has deliberately been left blank

Applicant’s Full Name:	DOB: E.g. dd-mm-yyyy

Applicant Agreement
I declare that all the information I have supplied on this application is true and correct to the best of my knowledge. I agree to enquiries being made by EnableNSW to other agencies and services for the purpose of obtaining information about eligibility and assessment for the requested equipment and/or service. I agree to the use and disclosure of my personal information, provided that it is necessary and relevant for the purpose of EnableNSW assisting me with the provision of equipment/repairs and services.* I accept that the available equipment that meets my assessed need and goal may be re-allocated or new. I acknowledge that the equipment is on loan to me for as long as I need it and I agree to return any equipment when it is no longer needed. I agree to care for any equipment received and to notify EnableNSW when repairs or maintenance are needed. I agree to reimburse EnableNSW for the cost of equipment, repairs and/or services provided in the event that a compensation claim results in a settlement relating to the condition for which the equipment/services were provided. I agree to be respectful and courteous to EnableNSW staff.
*Privacy: The information contained in this application is protected by law from unauthorised access and misuse. The information will only be accessed by health service staff directly involved in providing services to the applicant, or with other lawful excuse. For more information about privacy please visit our website at www.enable.health.nsw.gov.au.
Signature: Date of completion: E.g. dd-mm-yyyy

Thank you, you have now completed the EnableNSW application form. Before you send the application through, refer to the checklist on page 1 to ensure the application is sent with the correct documentation. Send the completed form to:

Email, Post or Fax to EnableNSW
Email: HSNSW-enable@health.nsw.gov.au
Post: EnableNSW HealthShare NSW Locked Bag 5270 PARRAMATTA NSW 2124
Fax: (02) 8797 6543

Author: EnableNSW	Document ID: FM100004	Author: EnableNSW
Approved by: Jackie Hiller	Version: 04	Approved by: Jackie Hiller
Modified: May 2018	Published: June 2018