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HEALTH SERVICE PATS FACSIMILE COVER SHEET THE FACSIMILE COVER SHEET MUST BE COMPLETED WITH ALL PATS FOLLOWING IHPT/PE FORMS PATIENTS PATS OFFICE see contacts TO FROM REGION WARD PHONE SENT VIA DISCHARGING HEALTH SERVICE FULL NAME PREFERRED RETURN CONTACT METHOD FAX EMAIL OF FAX PAGES DATE Affix Patient ID Label Dear PATS Clerk Please arrange transport for on date // The following checklist is to assist the Health Service in the discharge of PATS patients Checklist YES The patient is making their own way home and will contact you at a later date before 8 weeks to claim reimbursement Completed PATS following IHPT/PE form attached Completed Fitness to Fly form if required attached Requires wheelchair to seat - please inform airline of hoist requirement Clinically assessed as requiring escort Patient Identification photo or 3 forms of non photo ID - e.g. bank cards Medicare card - If no please inform airline The Patient is staying in Perth and will contact you at a later date to arrange transport Patient has been provided with PATS contact details if applicable Other requirements for travel e.g. oxygen Please specify Kind regards First name last name PATS following IHPT/PE formv1. 0 July 2012 NO PATIENT ASSISTED TRAVEL SCHEME PATS FOLLOWING INTER HOSPITAL PATIENT TRANSFER OR PRIMARY EVACUATION IHPT/PE FORM THIS FORM IS TO BE COMPLETED BY THE DISCHARGING HEALTH SERVICE AND EMAILED/FAXED TO THE PATIENT S PATS OFFICE FOR APPROVAL AND BOOKING OF RETURN TRAVEL AT THE EARLIEST POSSIBLE TIME PRIOR TO DISCHARGE. SECTION A PATIENT DETAILS MRN PERMANENT RESIDENTIAL ADDRESS PATIENT IS RETURNING TO If different please state MEDICARE NO DOB SEX M / F permanent residential address as above Hm Phone Perth Contact Mobile Did the PATS patient make a planned trip to the Hospital using pre-approved PATS Assistance If YES skip to Section C If NO complete Section B SECTION B PATS ELIGIBLITY FOR IHPT/PE PATIENTS Nb Patients who were Inter Hospital Patient Transfers / Primary Evacuations need to be assessed for PATS Eligibility. Patient was IHPT/PE FROM Is the Patient eligible for assistance through any other program or is a compensation or insurance claim pending Workers Compensation Motor Vehicle Accident If yes please specify Details Patient eligible for PATS if Yes to ALL of the following Veteran Affairs Patient came to Perth by IHPT/Primary Evacuation Patient is permanent country resident eligible for Medicare Patient is returning to permanent residential address or somewhere closer NB NOT PATS if being transferred back to country hospital Patient resides 100km from the discharging Hospital NB If NO to any of the criteria please contact the patients PATS Office for advice. HEALTH SERVICE PATS FACSIMILE COVER SHEET THE FACSIMILE COVER SHEET MUST BE COMPLETED WITH ALL PATS FOLLOWING IHPT/PE FORMS PATIENTS PATS OFFICE see contacts TO FROM REGION WARD PHONE SENT VIA DISCHARGING HEALTH SERVICE FULL NAME PREFERRED RETURN CONTACT METHOD FAX EMAIL OF FAX PAGES DATE Affix Patient ID Label Dear PATS Clerk Please arrange transport for on date // The following checklist is to assist the Health Service in the discharge of PATS patients Checklist YES The patient is making their own way home and will contact you at a later date before 8 weeks to claim reimbursement Completed PATS following IHPT/PE form attached Completed Fitness to Fly form if required attached Requires wheelchair to seat - please inform airline of hoist requirement Clinically assessed as requiring escort Patient Identification photo or 3 forms of non photo ID - e*g* bank cards Medicare card - If no please inform airline The Patient is staying in Perth and will contact you at a later date to arrange transport Patient has been provided with PATS contact details if applicable Other requirements for travel e*g* oxygen Please specify Kind regards First name last name PATS following IHPT/PE formv1.