Referral for Orthotic and / or Prosthetic Services (Assistive Technology - AT)

First Name *

Last Name *

Date of Birth *

Street Address *

Postal Address (if applicable)

Contact phone number *

Email Address

Contact person (if not patient)

Interpreter required?

Language

Funding Body

No funding (self-funded)Private Health Insurance (cover varies according to policy) NDISDVACompensable / Insurance / WorkcoverLSAAged Care Package

Funder / Member / Claim number

Funding Body Contact Person and Company

Contact Person Email

NDIS Budget Management

Self ManagedPlan ManagedAgency Managed

Plan Start Date

Plan End Date

Is Requested AT Listed on Current Plan?

Approved Funding Amount

Primary Diagnosis/ Reason for Referral *

Comorbidities Relevant to Referral

Proposed Orthotic / Prosthetic Treatment (desired functional outcome)

Therapy and / or Functional Goals

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E.g. imaging reports, hospital discharge letters, other relevant correspondence

Name of Referrer *

Date of Referral *

Profession of Referrer *

Provider Number

Phone Contact

Business Contact Details:

Prostek - 2 William Street, Mile End South - SA 5031

P: 08 8352 6511 - W: prostek.com.au - E: reception@prostek.com.au

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