ACT Interstate Patient Travel Assistance Scheme (ACT IPTAS) Claim Form (Reviewed: July 2023) Completed Form Examples and Samples
Explore detailed examples of the ACT Interstate Patient Travel Assistance Scheme (ACT IPTAS) Claim Form (Reviewed: July 2023). Our samples demonstrate how to accurately complete the form for various scenarios, including minor patients, escorts, and interstate referrals, providing a clear guide for your claim.
ACT IPTAS Claim Form Example – Minor Patient with Escorts and Interstate Referral
How this form was filled:
Our AI successfully extracted comprehensive patient, travel, and medical details from a combination of a GP's referral letter and a guardian's email. It automatically populated the ACT IPTAS Claim Form, correctly identifying the need for two escorts for a minor, the medical reasons for interstate travel and escort requirements, and the payment particulars.
Source document used: GP Referral Letter and Guardian's Email
Date: May 15, 2024 To Whom It May Concern, Patient: Olivia Grace Smith (DOB: 12/03/2010) I am writing to refer Olivia Grace Smith, a 14-year-old female patient residing at 15 Wattle Street, Weston Creek, ACT 2611, for specialist neurosurgical assessment. Olivia has been experiencing refractory epilepsy, which requires highly specialized diagnostic evaluation not currently available within the ACT. Her current Medicare card number is 1234 56789 1. She is a permanent resident of the ACT. I am referring her to Dr. Emily Roberts, a Paediatric Neurologist at the Children's Hospital at Westmead, Sydney, NSW. Dr. Roberts' contact number is 02 8899 0011. This service is considered the nearest appropriate specialist care for Olivia's complex condition. Due to Olivia's young age and the severity of her anxiety during extended travel, I strongly recommend that she be accompanied by an escort for both the travel and the treatment. The complex diagnostic procedures and potential cognitive impacts of her condition necessitate continuous parental presence for comfort, decision-making, and post-procedure care. She can travel by private car. Air travel is not specifically required for this journey. My practice details are: Dr. Alan Jenkins, 25 Clover St, Civic, ACT 2601. Provider Number: 123456DX. Phone: 02 6200 5500, Fax: 02 6200 5501, Email: [email protected]. Sincerely, Dr. Alan Jenkins --- Subject: IPTAS Claim - Olivia Smith - May 2024 Visit Hi IPTAS Team, I'm submitting a claim for Olivia's recent specialist visit to Sydney. Her appointment with Dr. Emily Roberts at the Children's Hospital at Westmead was on May 21, 2024, from 10:30 AM to 1:00 PM. We departed Canberra on May 20, 2024, and returned on May 22, 2024. The travel was by private car for both legs of the journey. I, Sarah Smith, was Olivia's primary escort, and my husband, David Smith, also accompanied us as a second escort since Olivia is a minor. We both stayed two nights in commercial accommodation near the hospital. Although we have private health insurance, our policy does not cover interstate medical travel expenses, only local hospital admissions, so no claim has been made there. We haven't made an IPTAS claim before, and we can't claim from any third party. Please make any payments to Sarah Smith, Commonwealth Bank, BSB 062-901, Account No 98765432. You can reach me at 0412 345 678 or my home phone 02 6288 1234, and my email is [email protected]. Attached are the receipts for accommodation and a completed Part C from Dr. Roberts. Thanks, Sarah Smith (Olivia's guardian)
Information used to fill out the document:
- Patient Name: Olivia Grace Smith
- Patient DOB: 12/03/2010
- Patient Address: 15 Wattle Street, Weston Creek, ACT 2611
- Medical Condition: Refractory Epilepsy
- Specialist Details: Dr. Emily Roberts, Paediatric Neurology, Children's Hospital at Westmead, Sydney, NSW
- Travel Dates: Departed: 20/05/2024, Appointment: 21/05/2024, Returned: 22/05/2024
- Escorts: Sarah Smith (primary), David Smith (second)
- Accommodation: 2 nights commercial accommodation for patient and escorts
- Bank Details: Sarah Smith, Commonwealth Bank, BSB 062-901, Account 98765432
What this filled form sample shows:
- Identified patient as a minor (14 years old) to correctly fill escort fields, including a second escort.
- Extracted specific medical reasons for interstate referral and escort requirements embedded in prose.
- Seamlessly combined information from a GP referral letter and a guardian's email to complete all sections.
- Determined private health fund status and reason for no claim from a natural language statement.
- Extracted various contact numbers and email addresses, correctly mapping them to the right fields.
Form specifications and details:
| Form identifier: | ACT IPTAS Claim Form Reviewed: July 2023 |
| Patient Surname: | Smith |
| Patient Given Name(s): | Olivia Grace |
| Title: | Ms |
| Date of Birth - Day: | 12 |
| Date of Birth - Month: | 03 |
| Date of Birth - Year: | 2010 |
| Female: | true |
| Aboriginal or Torres Strait Islander origin — No: | true |
| Needs help with interpreting English — No: | true |
| Permanent residential address: | 15 Wattle Street, Weston Creek, ACT 2611 |
| Email address: | [email protected] |
| Telephone (Home): | 02 6288 1234 |
| Mobile telephone: | 0412 345 678 |
| Can you claim from a Private Health Fund? — Yes: | true |
| Has a claim been made for travel/accommodation? — No: | true |
| Private Health Fund claim — reason if no claim made: | Policy does not cover interstate medical travel, only local hospital admissions. |
| Are you a permanent resident of the ACT? — Yes: | true |
| Medicare Card Details: | 1234 56789 1 |
| Have you ever made an IPTAS claim? — No: | true |
| Can you claim for Compensation, Insurance or Third Party? — No: | true |
| Travel destination (to): | Children's Hospital at Westmead, Sydney |
| Departure date (travel to): | 20/05/2024 |
| Departure date — day (I/We travelled on …): | 20 |
| Departure date — month/year (I/We travelled on …): | 05/2024 |
| Appointment/admission date — month/year (for an appointment / admission on …): | 05/2024 |
| Appointment / admission date: | 21/05/2024 |
| Appointment time: | 10:30 AM |
| Appointment/admission date — day (for an appointment / admission on …): | 21 |
| Return date — day (I/We returned to Canberra on …): | 22 |
| Return date (to Canberra): | 22/05/2024 |
| Patient - Transport to appointment: | Private Car |
| Patient - Transport to get home (receipt): | Private Car |
| Escort - Transport to appointment: | Private Car |
| Escort - Transport to get home: | Private Car |
| Second Escort Name (for patients under 18): | David Smith |
| Escort Name: | Sarah Smith |
| Patient nights in commercial accommodation: | 2 |
| Escort nights in commercial accommodation: | 2 |
| EFT or cheque payable to (payee name): | Sarah Smith |
| Bank name: | Commonwealth Bank |
| BSB: | 062-901 |
| Account name: | Sarah Smith |
| Account number: | 98765432 |
| Certification 1: Printed Name: | Sarah Smith |
| Certification 2: Signature: | true |
| Name (certifier): | true |
| Signature (Certification): | true |
| Date (Certification): | 23/05/2024 |
| Footer — Page Number: | 1 |
| Form header / identifier: | ACT IPTAS Claim Form Reviewed: July 2023 |
| Patient's Name: | Olivia Grace Smith |
| Interstate Treating Doctor and Location: | Dr. Emily Roberts at Children's Hospital at Westmead |
| Specialist's Name: | Dr. Emily Roberts |
| Specialty: | Paediatric Neurology |
| Telephone: | 02 8899 0011 |
| Location (Hospital/Institution): | Children's Hospital at Westmead |
| City/State: | Sydney, NSW |
| Primary medical condition to be treated: | Refractory Epilepsy |
| Additional details / secondary condition: | requiring specialized neurosurgical assessment |
| No - Specialist service available in the ACT: | true |
| Nearest to ACT - Yes: | true |
| Does the patient require an escort during travel? — Yes: | true |
| Escort during travel — medical reason: | Patient is a minor (14 years old) and suffers from severe anxiety during long travel, requiring continuous supervision and emotional support. |
| Does the patient require an escort during treatment? — Yes: | true |
| Escort during treatment – medical reason: | Patient is undergoing complex assessments for refractory epilepsy and requires parental presence for comfort, decision-making, and post-procedure care due to potential cognitive effects. |
| Can the patient travel by private car or public transport? — Yes: | true |
| Air travel recommended - No: | true |
| Official stamp: | Dr. Alan Jenkins, GP |
| Referring medical practitioner name: | Dr. Alan Jenkins |
| Private practice provider number: | 123456DX |
| Address: | 25 Clover St, Civic, ACT 2601 |
| Telephone number: | 02 6200 5500 |
| Fax number: | 02 6200 5501 |
| Referring medical practitioner's signature: | true |
| Referring Medical Practitioner's signature: Date - Month: | 05 |
| Referring Medical Practitioner's signature: Date - Day: | 15 |
| Referring Medical Practitioner's signature: Date - Year: | 2024 |
| text__b2f6: | Olivia Grace Smith |
| checkbox__0e26: | true |
| text__2959: | 21/05/2024 |
| text__38de: | 10:30am |
| text__43c7: | 1:00pm |
| checkbox__e6e0: | false |
| checkbox__d00f: | false |
| checkbox__74de: | false |
| checkbox__7893: | false |
| checkbox__ef4b: | true |
| text__68df: | 21/05/2024 |
| text__6b07: | 21/05/2024 |
| text__8ac7: | Due to complex diagnostic procedures and patient's young age, continuous parental support was medically necessary. |
| checkbox__86ea: | true |
| checkbox__8157: | true |
| text__f8a3: | Dr. Emily Roberts |
| text__2488: | 876543TR |
| text__0d22: | Children's Hospital at Westmead, Locked Bag 4001, Westmead NSW 2145 |
| text__8647: | 02 8899 0011 |
| text__5e7a: | 02 8899 0012 |
| text__4f8b: | [email protected] |
| text__71af: | true |
| text__c9e6: | 22/05/2024 |
| Categories: | patient forms, VA claim forms, patient travel assistance forms |
| Created: | March 10, 2026 06:52 AM |