ACT Interstate Patient Travel Assistance Scheme (ACT IPTAS) Claim Form (Reviewed: July 2023) Instructions

Enter the total number of nights the patient stayed in commercial accommodation for this journey as shown on the receipt.

Enter the total number of nights the escort(s) stayed in commercial accommodation for this journey as shown on the receipt.

Provide the full name of the person or organisation to whom the EFT or cheque should be payable.

Enter the name of the bank where the payee holds the account for reimbursement.

Enter the BSB (Bank State Branch) number of the payee's bank.

Provide the name on the bank account to which payment should be made (the account holder's name).

Enter the bank account number for the payee to receive the EFT or cheque payment.

Check this box when the referring practitioner recommends that the patient should travel by air; if checked, also provide the required medical reason in the space provided.

Check this box when the referring practitioner does not recommend air travel for the patient.

If air travel is recommended, enter the medical justification or explanation describing why air travel is required or appropriate for this patient (include any relevant clinical details). Fill only if 'Air travel recommended - Yes' Is Air Travel recommended? is 'Yes'.

Enter the end date for the first benefit period.

Enter the start date for the second benefit period.

Enter the category or type of travel benefit.

Enter the full printed name of the person certifying that the information on this form is true and accurate.

Provide the signature of the person certifying the information on this form.

Check this box after you have printed your full name in the certification statement beginning 'I, ____' to identify who is certifying the information.

Check this box after you have provided your handwritten signature on the 'Signature' line to confirm the certification.

Check this box after you have entered the date on the 'Date' line to indicate when the certification was signed.

Enter the patient's permanent residential address including street number and name, unit/flat if applicable, suburb, state/territory and postcode (include country if not in Australia).

Enter the postal or mailing address to receive correspondence if it differs from the permanent address (e.g., PO Box or alternate street address), including suburb, state/territory and postcode.

Enter the patient's email address to be used for contact.

Enter the patient's home telephone number, including the area code if required.

Enter the patient's work telephone number, including the area code if required.

Enter the patient's mobile phone number, including country or area code if appropriate.

Enter the full name of the second escort accompanying the patient (required when the patient is under 18 years). Fill only if 'Date of Birth - Day', 'Date of Birth - Month', 'Date of Birth - Year' indicates patient is under 18 years (all).

Enter the full name of the escort who accompanied the patient for the travel or appointment.

Check this box when the patient does require an escort during travel (if checked, provide the required medical reason in the form).

Check this box when the patient does not require an escort during travel.

Enter the medical reason or clinical justification explaining why the patient requires an escort during travel; provide sufficient detail for assessment (e.g., mobility, cognitive, behavioural or clinical care needs). Fill only if 'Does the patient require an escort during travel? — Yes' Does the patient require an escort during travel? is 'Yes'.

Check this box when the patient does require an escort to accompany them during treatment (if checked the referring practitioner must provide the medical reason).

Check this box when the patient does not require an escort during treatment.

Enter the medical justification explaining why the patient requires an escort during treatment; leave this blank if no escort is required. Fill only if 'Does the patient require an escort during treatment? — Yes' Does the patient require an escort during treatment? is 'Yes'.

Enter the month or day for the end date of the escort treatment/hospitalisation period.

Enter the month or day for the start date of the escort treatment/hospitalisation period.

Enter the year for the end date of the escort treatment/hospitalisation period.

Check this box if the patient required an escort during their treatment or hospitalisation period.

Enter any specific exception or additional information regarding rebates for staying in private accommodation for patient and/or escorts before 1 July 2023.

Enter the end time of the first appointment.

Enter the start time of the first appointment.

Check this box if the patient had their first appointment as indicated.

Enter the end time of the first subsequent appointment.

Enter the start time of the first subsequent appointment.

Check this box if the patient had their first subsequent appointment on the date provided.

Enter the rebate amount for private vehicle fuel costs for travel from 1 July 2023.

Enter the rebate amount for private vehicle fuel costs for travel before 1 July 2023.

Provide additional details or notes regarding the private vehicle fuel costs benefit.

Enter the page number shown in the form footer (for example "1").

Enter the form’s header or identifier as shown at the top of the page (for example the form number, code, or title used to identify this document).

Enter the form identifier or reference number printed on this form (e.g., the unique form ID shown in the top-right box).

Please enter the custom rebate amount for the Fourth Rail Travel Benefit before 1 July 2023.

Please enter the custom rebate amount for the Fourth Rail Travel Benefit from 1 July 2023.

Please enter any additional information or specific amount for the Fourth Rail Travel Benefit (Return).

Provide the date the patient was admitted to the hospital.

Check this box if the patient was admitted to the hospital.

Enter the month and day of the patient's discharge from the hospital.

Enter the year of the patient's discharge from the hospital.

Enter the main diagnosis or medical condition for which the patient is being referred for treatment (brief clinical name or description).

Provide any additional diagnoses, relevant clinical details, symptoms or secondary conditions related to the referral that clarify or supplement the primary condition.

Check this box if the specialist service named above is the nearest available to the ACT.

Check this box if the specialist service is not the nearest to the ACT; if checked, provide a medical reason in the space provided.

Provide the medical justification or clinical reason why the referred specialist is not the nearest to the ACT (explain why a more distant specialist is required); leave blank if the specialist is the nearest. Fill only if 'Nearest to ACT - No' Is the specialist service the nearest to ACT? is 'No'.

Check this box if the patient required outpatient treatment during the period specified by the 'from' and 'to' dates.

Check this box if overnight commercial accommodation was required prior to the patient's treatment.

Check this box if overnight commercial accommodation was required following the patient's treatment.

Provide any additional information relevant to the postal address, such as a country if outside Australia or a special instruction.

Provide any additional information relevant to the street address, such as a country if outside Australia or a special instruction.

Enter the referred patient's full name (given names and surname) as recorded in medical records.

Enter the interstate treating doctor's name and brief location details (clinic/hospital name and address or suburb).

Enter the specialist's full name (including title if desired).

Enter the specialist's medical specialty (for example: Cardiology, Orthopaedics, Dermatology).

Enter the specialist's contact telephone number including area/country code as applicable.

Enter the name of the treating hospital or institution and, if relevant, department or unit.

Enter the city and state where the treating hospital/institution is located (e.g., Sydney, NSW).

Enter the full name of the patient.

Enter the patient's family/last name exactly as it appears on their medical records or identification.

Enter the patient's given and middle name(s) (first name and any middle names) exactly as shown on their medical records or identification.

Check this box when you are indicating the patient’s title (e.g., Mr, Mrs, Ms) in the adjacent title field.

Check this box to indicate the day (DD) portion of the patient’s date of birth has been entered/confirmed.

Check this box to indicate the month (MM) portion of the patient’s date of birth has been entered/confirmed.

Check this box to indicate the year (YYYY) portion of the patient’s date of birth has been entered/confirmed.

Check this box when the patient is able to travel by private car or public transport (no medical restriction preventing such travel).

Check this box when the patient cannot travel by private car or public transport; if checked, provide the medical reason for this restriction.

Enter the medical explanation describing why the patient cannot travel by private car or public transport (provide sufficient clinical detail to justify the restriction). Fill only if 'Can the patient travel by private car or public transport? — No' Can the patient travel by private car or public transport? is 'No'.

Enter any privacy-related notes or additional comments relevant to this referral or claim (e.g., confidentiality instructions, extra information not captured elsewhere, or other remarks for staff).

Check this box if you can claim from a private health fund (i.e. answer 'Yes' to the question 'Can you claim from a Private Health Fund?').

Check this box if you cannot claim from a private health fund (i.e. answer 'No' to the question 'Can you claim from a Private Health Fund?').

If you have not made a claim to your private health fund for travel or accommodation, briefly state the reason why no claim was lodged. Fill only if 'Has a claim been made for travel/accommodation? — No' is 'No'.

If you answered 'Yes' to claiming from a private health fund, check this box if a claim has already been made for travel or accommodation. Fill only if 'Can you claim from a Private Health Fund? — Yes' is 'Yes'.

If you answered 'Yes' to claiming from a private health fund, check this box if no claim has been made for travel or accommodation; if selected, provide the reason in the space provided. Fill only if 'Can you claim from a Private Health Fund? — Yes' is 'Yes'.

Enter the reason why an escort is required.

Enter the practice or organisation official stamp text or brief identifier to indicate the referring practitioner's clinic/organisation (or type 'STAMP' if a physical stamp will be applied).

Enter the full name of the referring medical practitioner as it should appear on the form.

Enter the referring practitioner's private practice provider number (numeric provider/registration number).

Enter the full postal address of the referring practitioner or practice, including street, suburb, state and postcode.

Enter the clinic or practitioner's telephone number including area or country code as needed.

Enter the clinic or practitioner's fax number if available, including area or country code as needed.

Enter the referring practitioner's email address for correspondence.

Provide the referring practitioner's signature or typed name to confirm and authorise the referral.

Check this small box to indicate/record the month (MM) portion of the date when the referring practitioner signed the form.

Check this small box to indicate/record the day (DD) portion of the date when the referring practitioner signed the form.

Check this small box to indicate/record the year (YYYY) portion of the date when the referring practitioner signed the form.

Enter the patient’s Medicare card information as shown on the card (e.g., card number and reference details) to verify Medicare entitlement. Fill only if 'Are you a permanent resident of the ACT? — Yes' is 'Yes'.

Check this box if the patient is a permanent resident of the Australian Capital Territory (ACT).

Check this box if the patient is not a permanent resident of the Australian Capital Territory (ACT).

Check this box if the patient has previously made an ACT IPTAS (interstate patient travel assistance) claim.

Check this box if the patient has never made an ACT IPTAS claim.

Check this box if the patient can claim travel or accommodation costs from compensation, an insurance provider, or a third party.

Check this box if the patient cannot claim travel or accommodation costs from compensation, an insurance provider, or a third party.

Provide the start time for the second subsequent appointment.

Provide the end time for the second subsequent appointment.

Check this box if the patient had a second subsequent appointment on the date indicated.

Provide any applicable rebate amount for private electric vehicles (at commercial charge stations only) for travel before July 1, 2023. Note: The adjacent text indicates 'N/A' for this period.

Provide any applicable rebate amount for private electric vehicles (at commercial charge stations only) for travel from July 1, 2023.

Check this box if the specialist service required is available in the ACT (either publicly or privately).

Check this box if the specialist service required is not available in the ACT and an interstate referral is required.

Enter the specific clinical or logistical reason the patient must be referred interstate for this specialist service (for example: not available in ACT, no local subspecialist, excessive wait times, required specialist expertise, or patient circumstances). Fill only if 'Yes - Specialist service available in the ACT' Is the specialist service required available in the ACT, either publicly or privately? is 'Yes'.

Check this box if the patient identifies as male.

Check this box if the patient identifies as female.

Check this box if the patient identifies as being of Aboriginal or Torres Strait Islander origin.

Check this box if the patient does not identify as being of Aboriginal or Torres Strait Islander origin.

Enter the patient’s preferred language for communication or the language required for an interpreter (for example: English, Mandarin, Arabic). Fill only if 'Needs help with interpreting English — Yes' is 'Yes'.

Check this box if the patient needs help with interpreting English.

Check this box if the patient does not need help with interpreting English.

Provide the signature of the treating medical specialist or authorized representative.

Enter the year part of the signature date.

Enter the month or day part of the signature date.

Please provide the maximum carparking costs claimable for travel before 1 July 2023.

Enter the start time of the third subsequent appointment.

Enter the end time of the third subsequent appointment.

Check this box if the patient had a third subsequent appointment.

Enter the amount claimed for coach travel to the selected destination before 1 July 2023.

Enter the amount claimed for coach travel to the selected destination from 1 July 2023.

Specify the destination city for which the coach travel benefit is being claimed.

Enter the mode of transport the patient used to travel to the appointment (for example: private car, taxi, bus, train, plane, or other).

Enter the mode of transport the patient used to return home and, if you are claiming costs, ensure the corresponding receipt is attached or provided.

Enter the mode of transport the escort used to travel to the patient’s appointment (for example: private car, taxi, bus, train, plane, or other).

Enter the mode of transport the escort used to return home after the appointment (for example: private car, taxi, bus, train, plane, or other).

Enter the location, clinic or hospital the patient travelled to from Canberra for this appointment or admission.

Enter the date on which you travelled to the destination for the appointment or admission.

Check this box to indicate or confirm the day portion of the date you travelled from Canberra to the appointment.

Check this box to indicate or confirm the month (and year) portion of the date you travelled from Canberra to the appointment.

Check this box to indicate or confirm the month (and year) portion of the date of the appointment or hospital admission.

Enter the date of the appointment or hospital admission for which travel was undertaken.

Enter the time of the appointment or hospital admission (AM/PM as applicable).

Check this box to indicate or confirm the day portion of the date of the appointment or hospital admission.

Check this box to indicate or confirm the day portion of the date you returned to Canberra.

Enter the date on which you returned to Canberra after the appointment or admission.

Enter the time at which you returned to Canberra after the appointment or admission.

Enter the full name of the treating specialist or authorized representative.

Enter the provider number of the treating specialist or authorized representative.

Enter the first line of the treating specialist's or authorized representative's address.

Enter the second line of the treating specialist's or authorized representative's address.

Enter the telephone number of the treating specialist or authorized representative.

Enter the fax number of the treating specialist or authorized representative.

Enter the email address of the treating specialist or authorized representative.