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Provider forms
Last updated:
30 June 2020
Use these forms to arrange treatment and support services for veterans and their dependents who have DVA health cards.
Healthcare professionals seeking further information about DVA health arrangements and programs please visit the DVA providers page.
If you need assistance with DVA forms, call us on 1800 555 457.
Displaying 1 - 69 of 69
| Form ID | Title | Audience |
|---|---|---|
| D9353 | D9353 Activities of daily living assessment | For providers, Occupational therapist (general) |
| D9076 | D9076 Acute Care Certificate | For providers, Hospitals & day procedure centres |
| D0695 | D0695 Allied health time based voucher | For providers, Chiropractor, Diabetes educator, Dietitian, Exercise physiologist, Medical specialist, Neuropsychologist, Occupational therapist (general), Occupational therapist (mental health), Optometrist, Orthoptist and Optical dispenser, Orthotist, Osteopath, Physiotherapist, Podiatrist/Footwear prescriber, Psychologist, Social worker (general), Social worker (mental health), Speech pathologist |
| D1004 | D1004 Application for Community Nursing Exceptional Case Status | For providers, Community nursing, Registered Nurse |
| D9208 | D9208 Application for Licence to Reproduce Department of Veterans' Affairs Card Images | For providers, Pharmacist |
| D9140 | D9140 Application for Positive Airways Pressure (PAP) Equipment | For providers, Hospitals & day procedure centres, Medical specialist |
| D1206 | D1206 Application for Provider Registration for an Orthoptist | For providers, Optometrist, Orthoptist and Optical dispenser |
| D9173 | D9173 Application to list or modify price of a product on the RSPB | For providers, Pharmacist |
| D9199 | D9199 Assessment form for the supply of a Personal Response System | For providers, General Practitioner, Medical specialist, Occupational therapist (general), Physiotherapist, Registered Nurse |
| D1004A | D1004A Attachment 1 Exceptional Case — Dementia / Short Term Memory Loss/ Confusion | Community nursing, General |
| D1004B | D1004B Attachment 2 Exceptional Case — Mental Health | For providers, Community nursing |
| D1004C | D1004C Attachment 3 Exceptional Case — Palliative Care | For providers, Community nursing |
| D1004D | D1004D Attachment 4 Exceptional Case — Wound Care | For providers, Community nursing |
| D1323 | D1323 Authority to install/modify | Occupational therapist (general) |
| D9294 | D9294 Chiropractic/Osteopathy/Physiotherapy Prior Financial Approval Request | For providers, Chiropractor, Osteopath, Physiotherapist |
| D1217CN | D1217CN Claim for Treatment Services - Community Nursing | For providers, Community nursing |
| D1217 | D1217 Claim for treatment services voucher | For providers, Chiropractor, Clinical psychologist, Dental prosthetist, Dental specialist, Dentist, Diabetes educator, Dietitian, Exercise physiologist, General Practitioner, Hospitals & day procedure centres, Medical specialist, Neuropsychologist, Occupational therapist (general), Optometrist, Orthoptist and Optical dispenser, Orthotist, Osteopath, Physiotherapist, Podiatrist/Footwear prescriber, Psychologist, Social worker (mental health), Speech pathologist, General |
| D1083 | D1083 Community Nursing Service Voucher | For providers, Community nursing |
| D1353 | D1353 Confirmation of attendant care services | Attendant care service provider, General |
| D0988 | D0988 Continence direct order form | For providers, General Practitioner, Medical specialist, Occupational therapist (general), Occupational therapist (mental health), Physiotherapist, Registered Nurse |
| D6345 | D6345 Coronary Care Patient Certificate | For providers, Hospitals & day procedure centres, Medical specialist, Registered Nurse |
| D1305 | D1305 CVC Program Community Nursing LMO/GP Feedback | For providers, Community nursing, General Practitioner |
| D9166 | D9166 D9166 - Order form for Non-nutritional Thickened Fluid Products | General Practitioner, Speech pathologist |
| D9257 | D9257 D9257 - Order form for low vision products | For providers, Hospitals & day procedure centres, Medical specialist, Occupational therapist (general), Optometrist, Orthoptist and Optical dispenser, Registered Nurse |
| D0919 | D0919 Dental report and voucher | For providers, Dental prosthetist, Dental specialist, Dentist |
| D0986 | D0986 Dental Request for Prior Approval for Treatment or Referral to a Specialist | For providers, Dental prosthetist, Dental specialist, Dentist, Medical specialist |
| D0653A | D0653A Discharge Advice and Hospital Claim | For providers, Hospitals & day procedure centres |
| D9132 | D9132 Dose Administration Aid (DAA) service VSMR | For providers, Pharmacist |
| D9255 | D9255 DVA Rehabilitation Consultant Registration | Rehabilitation service provider, General |
| D0904 | D0904 DVA request/referral voucher | For providers, General Practitioner |
| D9367 | D9367 DVA work trial agreement | For providers, Rehabilitation service provider |
| D1307 | D1307 Exceptional Case Status — Variation or Interruption to Care form | For providers, Registered Nurse |
| D0804 | D0804 Home Medical Oxygen Therapy and/or Respiratory Home Therapy Appliances form | For providers, General Practitioner, Hospitals & day procedure centres, Medical specialist, Physiotherapist, Registered Nurse |
| D1327 | D1327 Home/Access Modifications Assessment Form for all Major Modifications | For providers, Occupational therapist (general) |
| D0652B | D0652B Hospital Admission Voucher | For providers, Hospitals & day procedure centres |
| D6346 | D6346 Intensive Care Patient Certificate | For providers, Hospitals & day procedure centres, Medical specialist, Registered Nurse |
| D9283 | D9283 Job Seeking Questionnaire | For providers, Rehabilitation service provider |
| D9230 | D9230 Life Satisfaction Indicators | For providers, Rehabilitation service provider |
| D09382 | D09382 Medical Certificate - Ability to Work | General Practitioner, General |
| D9291 | D9291 Medical Disclosure Authority (multiple practitioners) | For providers, General Practitioner, Hospitals & day procedure centres, Medical specialist, Rehabilitation service provider |
| D9290 | D9290 Medical Disclosure Authority (single practitioner) | For providers, General Practitioner, Hospitals & day procedure centres, Medical specialist |
| D0688 | D0688 Medical grade footwear (MGF) prescription form | For providers, Orthotist, Podiatrist/Footwear prescriber |
| D0992 | D0992 Mobility Functional Support (MFS) products order form | For providers, General Practitioner, Hospitals & day procedure centres, Medical specialist, Occupational therapist (general), Physiotherapist, Rehabilitation service provider |
| D9292 | D9292 MRI/PET Scan Prior Financial Approval Request form | For providers, Hospitals & day procedure centres, Medical specialist |
| D1372 | D1372 Optical dispensing registration form | For providers, Medical specialist, Optometrist, Orthoptist and Optical dispenser |
| D1399 | D1399 Optical treatment prior financial approval request | For providers, Optometrist, Orthoptist and Optical dispenser |
| D9352 | D9352 Orthotist prior financial approval request form | For providers, Orthotist |
| - | - Outreach Program Counsellor (OPC) statutory registration form | For providers, Clinical psychologist, Psychologist, Social worker (mental health) |
| D9299 | D9299 Post Home Modification Report | For providers, Occupational therapist (general) |
| D9314 | D9314 Prior Approval Request for Alcohol & Other Substance Abuse treatment | For providers, Clinical psychologist, Hospitals & day procedure centres, Medical specialist, Neuropsychologist, Psychologist, Social worker (mental health) |
| D1334 | D1334 Rehabilitation assessment report | Rehabilitation service provider, General |
| D1347 | D1347 Rehabilitation Plan | For providers, Rehabilitation service provider |
| D1336 | D1336 Rehabilitation Plan Amendment | Rehabilitation service provider, General |
| D1335 | D1335 Rehabilitation Plan Closure | Rehabilitation service provider, General |
| D1330 | D1330 Rehabilitation plan progress report | Rehabilitation service provider, General |
| D1382 | D1382 Request for assistive communication device and/or speech pathology apps/software | For providers, Medical specialist, Speech pathologist |
| D9376 | D9376 Request for assistive listening devices and/or tinnitus devices | For providers, Audiologist, General Practitioner, Hospitals & day procedure centres, Rehabilitation service provider, General |
| D9160 | D9160 Request for exercise bike | For providers, Chiropractor, Exercise physiologist, General Practitioner, Medical specialist, Osteopath, Physiotherapist |
| D9165 | D9165 Request for nutritional supplementation | Dietitian, General Practitioner, Hospitals & day procedure centres |
| D9323 | D9323 Request for Prior Approval for Dental Implants | For providers, Dental prosthetist, Dental specialist, Dentist, Hospitals & day procedure centres, Medical specialist |
| D9356 | D9356 Request for psychiatric assistance dog prior approval form - RAP | For providers, Clinical psychologist, Medical specialist, Neuropsychologist, Occupational therapist (general), Occupational therapist (mental health), Psychologist, Social worker (mental health) |
| D9284 | D9284 Retraining Questionnaire | For providers, Rehabilitation service provider |
| D9300 | D9300 Scooter/electric wheelchair part 1 medical questionnaire - RAP | For providers, General Practitioner |
| D1325 | D1325 Scooter/electric wheelchair part 2 assessment form - RAP mobility and functional support products | Occupational therapist (general), Occupational therapist (mental health) |
| D0931 | D0931 Spectacles prescription | For providers, Optometrist, Orthoptist and Optical dispenser |
| TFI01 | TFI01 Tinnitus Functional Index Questionnaire and Scoring Instructions | For providers, Audiologist |
| D1328 | D1328 Treatment prior financial approval request | For providers, Chiropractor, Clinical psychologist, Dental prosthetist, Dental specialist, Dentist, Diabetes educator, Dietitian, Exercise physiologist, General Practitioner, Hospitals & day procedure centres, Medical specialist, Neuropsychologist, Occupational therapist (general), Optometrist, Orthoptist and Optical dispenser, Orthotist, Osteopath, Physiotherapist, Podiatrist/Footwear prescriber, Psychologist, Social worker (mental health), Speech pathologist |
| D1306 | D1306 VHC Feedback to GP for CVC Program | For providers, General Practitioner, Veterans' Home Care |
| D1338 | D1338 Vietnam Veterans' Sons and Daughters Support Program (VVSDSP) - prior approval form | For providers, Chiropractor, Clinical psychologist, Dental prosthetist, Dental specialist, Dentist, Dietitian, Exercise physiologist, General Practitioner, Hospitals & day procedure centres, Medical specialist, Neuropsychologist, Occupational therapist (general), Occupational therapist (mental health), Optometrist, Orthoptist and Optical dispenser, Orthotist, Osteopath, Physiotherapist, Podiatrist/Footwear prescriber, Psychologist, Social worker (general), Social worker (mental health), Speech pathologist, General |