IPTAAS Claim Form - EnableNSW

IPTAAS Registration ELIGIBILITY DETAILSHave you claimed, or are you entitled to Claim , travel and/or accommodation benefits from any of the following:1. Any Australian, State or Territory government scheme other than IPTAAS ?2. As part of a Workers Compensation Claim ?3. As part of any insurance Claim ?4. Do you have a Veterans Affairs (DVA) Gold Card?YesNoYesNoYesNoYesNoIf you are uncertainabout your eligibilityplease contact yournearest IPTAASO ffice to confirmAlternate contact person detailsNamePhone PATIENT DETAILSE mail addressDaytime phone numberMobile numberResidential addressPostcodePostal addressPostcodeAre you Aboriginal/Torres Strait Islander?YesNoMedicare card detailsCard numberPosition on cardPreferred contact methodEmailMailDaytime phoneMobile phonePART 1 PATIENT AND ESCORT ESCORT DETAILS (if applicable)An escort is a person who, for medical reasons, is required to accompany an IPTAAS patient while travelling to specialist medical treatmentIf this Claim is the first visit to your Specialist / Prothotist / Orthotist or eligible Allied Health Professional,please also complete an IPTAAS Doctor Referral nameMiddle nameDate of birthTitleSurnameGiven nameMiddle name(01/16)Page 1 of 5 Isolated Patients Travel and AccommodationAssistance Scheme ( IPTAAS ) Claim FormI/We authorise: EnableNSW to use Centrelink Confirmation eServices to perform a Centrelink/DVA enquiry of my Centr

IPTAAS Registration number 1.1 ELIGIBILITY DETAILS Have you claimed, or are you entitled to claim, travel and/or accommodation benefits from any of the following:

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