MASS26 v2.04 - 03/2016 Page 1 of 2

Medical Aids Subsidy Scheme (MASS), Queensland Health

Administrative eligibility is dependent upon the applicant being a permanent Queensland resident. The applicant must hold one of the following eligibility cards – in the name of the applicant:

• CentrelinkPensionerConcessionCard• CentrelinkHealthCareCard• CentrelinkConfirmationofConcessionCardEntitlementForm(conditionsapply)• DepartmentofVeterans’Affairs(DVA)PensionerConcessionCard(conditionsapply)• QueenslandGovernmentSeniorsCard

To confirm eligibility: Please provide a signed consent to access Centrelink information (MASS 84 Proxy Access to Centrelink Information Form) OR a copy of both sides of the eligibility card.Clinical eligibility will be determined by the Medical Aids Subsidy Scheme (MASS) Clinical Advisor based on information provided by the prescribing therapist as required in the MASS General Guidelines (http://www.health.qld.gov.au/mass/)

Eligibility - MASS Subsidy

Applicant Information Sheet for MASS 26REQUEST TO TRIAL MASS STOCK EQUIPMENT

Thepersonwhowillreceivetheequipment(theApplicant)shouldretainthissectionfortheirrecords.

How to Apply - MASS

Applicant’s wishing to apply for subsidy funding for aid/s through MASS/CAEATI must consult an Occupational Therapist (OT), Physiotherapist (PT), Rehabilitation Engineer (RE) or for rural and remote areas only, a Registered Nurse in conjunction with an Occupational Therapist or Physiotherapist. The clinician will provide an assessment of your needs and assist you in choosing the most appropriate equipment for your needs.• ToapplyforMASSTrialEquipmentpleasecompleteSectionsBandCofthisform.• SectionAandDmustbesubmittedtofinaliseallocationofMASSStockEquipment.

Applicant Acknowledgement

I confirm that: 1 I have actively participated in the assessment and trial of aid/s and associated modificationsandaccessories.2 the features and options of the aid/s, and any appropriate alternatives have been fully explained to me by my prescribing health professional.3 thepossiblecostimplicationsthatImayincurasaresultofMASS/CAEATIpolicyorsubsidy funding have been explained to me by my prescribing health professional.4 the aid/s prescribed are suitable for my needs.5 Ihaveasafetyswitch/residualcurrentdeviceinstalledinmyhome(onlyapplicable

forMASSsubsidyfundedmobilityanddailylivingaidsthatrequirecharging/ operationthroughmainspower).

I acknowledge that the aid/s provided by MASS are on permanent loan and: 6 remainthepropertyofMASS,unlessadvisedbyMASSinwriting. 7 will only be used by me for the purposes prescribed.8 willbemaintainedbymeonaweekly/monthlybasisasoutlinedintheinformation provided to me with the aid.9 mustbereturnedtoMASSwhenInolongerrequireitsuseoritisreplaced,unless advisedbyMASSinwriting.10couldbeallocatedfromexistingMASSstock.MASSmaychoosetoreallocatesuitable

aid/s and not purchase new.

11 mustnothaveanyrepairsand/ormodificationscarriedoutwithoutspecificprior approvalbythelocalMASSservicecentrei.e.BrisbaneorTownsville.12 MASStakesnoresponsibilityforanyinjurysustainedbymethroughuseoftheaid subsidyfunded/allocatedbyMASS.13 unlesstheequipmentissuppliedtomewithwrittennotificationthatithasbeen

tested for electrical safety and that the equipment was found to be electrically safe, I should assume that it has not been tested and where the assumption applies, QueenslandHealthmakesnowarrantyastotheelectricalsafetyoftheequipment.

MASS26 v2.04 - 03/2016 Page 2 of 2

MASS Privacy Statement

YOUR PRIVACY:TheQueenslandHealth,MedicalAidsSubsidyScheme(MASS)collectsadministrative,demographicandclinicaldataaspartoftheMASSapplicationprocesses,inaccordancewiththeInformation Privacy Act 2009 and Health Services Act 2011, in order to assess your eligibility for funding assistance for the supply of aids and equipment.

TheinformationwillonlybeaccessedbyQueenslandHealthofficers.Someofthisinformationmaybegiventotheapplicant’scarerorguardian;othergovernmentdepartmentswhoprovideassociatedservices;theprescribinghealthprofessionalforfurtherclinicalmanagementpurposes;andtothoseparties(e.g.commercialsuppliers,communitycareandrepairers)requiringtheinformationforthepurposeofprovidingaids,equipmentandservices.

Your information will not be given to any other person or organisation except where required by law.

I agree to: 14 havingphotographs/videofootagetakentoassistwithmyapplication(forpowerwheelchairs,optionalforotheraids).RefertoMASS 82 ConsentforPhotograph/VideoForm.

15 answerpromptlyanyenquiriesmadefromtimetotimebyMASSservicecentreastotheconditionofthe aids and my continued need for its safe and effective use.

16 notifymylocalQueenslandHealthCommunityHealthCentreorlocalMASSservicecentreshould I cease to be able to use the aid/s safely and effectively.

17 usetheaid/swithintheconditionsofMASS.18 informMASSwithin14daysofanychangeinmyresidentialaddressoreligibilityforMASSsubsidy

fundingassistance.Forexample:– nolongereligibleforahealthcarecard;– inreceiptofaHomeCarePackagelevel3or4;– inreceiptofaConsumerDirectedCare(CDC)packagelevel3or4;– admission to a residential facility etc.

I understand that if I have taken ownership of a MASS subsidised aid that:19 repairs and maintenance become my responsibility. 20 insurance cover becomes my responsibility.

Medical Aids Subsidy Scheme, Brisbane PO Box 281, Cannon Hill Qld 4170 Telephone: 3136 3524 Fax: 3136 3525 Email: MASS-Equipment@health.qld.gov.auWebsite: www.health.qld.gov.au/mass

Medical Aids Subsidy Scheme, Townsville PO Box 980, Hyde Park Qld 4812 Telephone: 4433 8000 Fax: 4433 8001 Email: MASS-Equipment-TSV@health.qld.gov.auWebsite: www.health.qld.gov.au/mass

Pleasesendcompletedformviapostoremailto:

Medical Aids Subsidy Scheme(MASS) Queensland Health

(Affix identification label here if available)©

The

Sta

te o

f Que

ensl

and

(Que

ensl

and

Hea

lth) 2

012

Con

tact

CIM

@he

alth

.qld

.gov

.au

v2.04-

03/

2015

Page 1 of 10

Carer Information

PART A – Applicant Details

Applicant’s Personal Details

14 NameTitle Family name

Given name(s)

15 Contact informationTelephone Fax

Mobile

Email

16 Relationship to applicant

17 Postal address

Suburb / town Postcode

9 Does the applicant receive a Department of Veterans’ Affairs benefit?

10 Does the applicant receive other assistance? (e.g. Dept of Communities / Disabilities, Palliative Care services)If yes, name

11 Is the applicant of Aboriginal or Torres Strait Islander origin? For applicants of both Aboriginal and Torres Strait Islander origin, tick both ‘Yes’ boxes.

Aboriginal Yes NoTorres Strait Islander Yes No

12 Country of birth Australia Other

13 Language spoken at home English Other

Yes No

Yes No

Yes No

7 Is the applicant receiving a Home Care Package?Note: If the applicant will be receiving a Home Care package or CDC High Care Package at hospital discharge you should mark ‘Yes’.

Level 1 Level 2 Level 3 Level 4

1 NameTitle Family name

Given name(s)

Preferred name First name or specify

2 MASS reference number (if known)

3 Date of birth Sex Male Female

4 Permanent residential address

Suburb / town Postcode

Telephone Fax

Mobile

Email

5 Delivery address Same as residential address

Suburb / town Postcode

6 Postal address Same as residential address(for correspondence)

Suburb / town Postcode

8 Is the applicant a resident in a Commonwealth funded care facility?

Enter ACFI Score of L (Low), M (Medium) or H (High) for: ADL _____ Behaviour______ Complex Care______

Yes No

MASS 26Request to TrialMASS Stock Equipment

Family name:

Given name (s):

Date of Birth:

Address:

Phone Number: Sex: M F I

SW80

28S

W80

28

Medical Aids Subsidy Scheme(MASS) Queensland Health

Page 2 of 10

Alternate Contact Persons

Compensation or Insurance Claims

18 I consent to MASS, Queensland Health approaching my personal contacts should the need arise.The names and addresses of two (2) personal contacts who are aware that their names have been provided to MASS, who do not reside with the applicant and who will always be aware of the applicant’s address are:

19 Does a WorkCover, third party, public risk or any other form of compensation or insurance claim apply for injuries for which assistance from MASS, Queensland Health is requested?

Yes, please complete details below: No, go to the next section, Service Improvement Activities

• I have / have not engaged a legal representative to act on my behalf regarding a claim for damages.

• I undertake to repay MASS the cost of assistance provided to me by MASS, should I obtain damages forinjuries from any past, present or future claim/s.

• I undertake to advise MASS of the progress of my claim for damages. This may be in the form of writtencommunication to MASS from my legal representative.

• I provide authority for MASS to write to and provide information to my legal representative named above.• This authority remains valid until revoked by me in writing.

Solicitor’s name Firm’s name

Firm’s address Suburb Postcode

Telephone Fax Email

Applicant / Carer signature

Print name Date

Witnesssignature

Print name Date

Personal Contact 1 Personal contact 2Name in full Relationship to applicant Name in full Relationship to applicant

Address Address

Telephone Mobile Telephone Mobile

Fax Email Fax Email

Service Improvement Activities20 I agree to participate in MASS service improvement activities (including internal audits and surveys).

Yes NoAt any time I can withdraw my agreement by contacting the MASS Quality Systems Coordinator on 07 3136 3614. I understand that there will be no effect to service provision by MASS if I withdraw my consent.

Applicant Acknowledgement21 I agree to the conditions stated in the Applicant Information Sheet.22 I acknowledge that my information listed in this application is current and correct.23 Applicant/Carer signature

Print name Date

(Affix identification label here if available)

MASS 26Request to TrialMASS Stock Equipment

Family name:

Given name (s):

Date of Birth:

Address:

Phone Number: Sex: M F I

Medical Aids Subsidy Scheme(MASS) Queensland Health

Page 3 of 10

PART B – Prescriber Assessment

Functional Assessment1 What is the applicant’s permanent disability that necessitates assistive equipment.

2 Provide other relevant information including functional changes and/or comorbidities

3 What are the applicant’s measurements?

Height cm Weight kg

4 Describe your applicant’s functional status and abilities in the following areas:A. Physical function

Mobility Walks Independently

Walk with Assistance or Aid. Please specify:

Manual Wheelchair Please specify: self-propelled attendant-propelled

Power Wheelchair

Balance Functional Decreased Non-Functional

Transfers Independent Independent with aids. Please specify:

Carer assistance. Please specify:

Hoist

(Affix identification label here if available)

MASS 26Request to TrialMASS Stock Equipment

Family name:

Given name (s):

Date of Birth:

Address:

Phone Number: Sex: M F I

The completed request to trial form is to be faxed or emailed to the relevant MASS Equipment Services Team for processing – Brisbane Fax: 07 3136 3525 Email: MASS-Equipment@health.qld.gov.au

Townsville Fax: 07 4433 8001 Email: MASS-Equipment-TSV@health.qld.gov.auPlease provide a copy of both sides of the eligibility card, OR signed consent to access Centrelink information on the MASS84 Proxy Access to Centrelink Information Form.

Medical Aids Subsidy Scheme(MASS) Queensland Health

Page 4 of 10

Functional Assessment continued

Postural control in sitting Full Limited Non-functional

Skeletal deformity Yes No

If yes, please specify:

Describe upper and lower limb function

5 Please provide other relevant information in regards to the applicant:

6 Describe the applicant’s living situation (e.g. lives alone, receives carer support etc).

Alone Alone with informal support Alone with formal support With Family/Carer

Other: ____________________________________________________________________________________

(Affix identification label here if available)

MASS 26Request to TrialMASS Stock Equipment

Family name:

Given name (s):

Date of Birth:

Address:

Phone Number: Sex: M F I

� � � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � � � � � � �

� � � � � � � � �

� � � � � � � � � � � � � � � ! � � � � � � � " � � � � # � � � � � � � �$ % & ' ( ) * % & + ,- ' . + * * % & + / 0 1 ,2 % 3 + 4 5 6 ' 7 3 8 ,9 : : 7 + 0 0 ,; 8 4 * + < = & > + 7 , � ? � @ AB C D E F E G D H I J K L E C H M F N D H F O P Q R R S E F T U K E D V S W E G D I T T C H I T X F O E G D J C Y Z K S G D L P Q R R S E F T U Z K S E T I M M F E Y D[ C I H I M E D D L \] ^ % 1 _ % . + ) 4 = ` 4 * a 7 & + : b ' 3 8 c 9 d d 0 3 % 5 5 3 8 % 3 3 8 + 7 + e = + 0 3 + : 0 3 4 ` f ' 3 + & 0 % 7 + % . % ' ( % > ( + 5 4 7 3 7 ' % ( gh + 0 i j 7 4 ` + + : 3 4 k = + 0 3 ' 4 * l < 4 i m 4 * 3 % ` 3 c 9 d d i 0 3 4 ` f n 8 + % ( 3 8 ^ e ( : ^ o 4 . ^ % = 3 4 ` 4 * a 7 & % * : 7 + 0 + 7 . +' 3 + & 0 j 7 ' 4 7 3 4 j 7 4 ` + + : ' * ol ^ p 3 + & 0 7 + e = + 0 3 + : ,_ 4 ' 0 3 ; ( % e = + * = & > + 7p 3 + & * % & + ,d ( ' * o 3 ) j + ,c d m ; ( % e = + * = & > + 7p 3 + & * % & + ,d + % 3 d 3 ) ( + ,; % * % * : q % ` f h + 0 < 4; q c c % 3 3 7 + 0 0 j ( % e = + * = & > + 7; = & j j ( % e = + * = & > + 7 ,p 3 + & * % & + ,

; q m ; ( % e = + * = & > + 7 r ' : 3 8 2 + j 3 8p 3 + & * % & + ,c r m ; ( % e = + * = & > + 7 s ) j + 4 5 c r m , $ 4 ( : ' * op 3 + & * % & + ,

q ' o ' :d + % 3 r ' : 3 8 , d + % 3 2 + j 3 8 s ' ( 39 7 & 7 + 0 3 s ) j + , _ + % . ) 2 = 3 )6 % ` f 7 + 0 3 s ) j + , 6 % ` f 7 + 0 3 8 + ' o 8 3 ,s ) j + 4 5 $ 4 4 3 j ( % 3 + 0 , d + % 3 3 4 t 4 4 7 8 + ' o 8 3 ,; r m ; ( % e = + * = & > + 7p 3 + & * % & + ,u 3 8 + 7 ; ( % e = + * = & > + 7p 3 + & * % & + ,v ^ ; 7 + 5 + 7 7 + : 5 + % 3 = 7 + 0 w % ` ` + 0 0 4 7 ' + 0 4 5 ' 3 + & / + ^ o ^ 0 b ' * o i % b % ) 5 4 4 3 j ( % 3 + 0 1

Medical Aids Subsidy Scheme(MASS) Queensland Health

Page 6 of 10

Equipment – Request cont.

4

5

6

7

Is this equipment required for discharge from hospital, transition care or post-acute services? Yes No

a) Has the applicant had one or more falls in the last month? Yes No

b) Is the aim of the requested item to prevent future falls? Yes No

a) Does the applicant have a current pressure injury? Yes No

b) Is the aim of the requested item to manage a current pressure injury? Yes No

Please specify delivery address of trial item:

Applicant:

Prescriber:

Other Address:

Collected by prescriber: Name: Date of collection:

Reason for this Application

8 Provide details of the functional or other issues that will be resolved with the provision of this equipment.

Why does the current equipment need replacing?

Not Applicable No longer meets client needs MASS Requested Replacement Beyond Economic Repair(Provide reason) (Describe condition of equipment)

(Affix identification label here if available)

MASS 26Request to TrialMASS Stock Equipment

Family name:

Given name (s):

Date of Birth:

Address:

Phone Number: Sex: M F I

Medical Aids Subsidy Scheme(MASS) Queensland Health

Page 7 of 10

Equipment Prescription

9 Does the applicant need tilt in space? Yes No

If yes, provide a reason (select all that apply)

Achieve or maintain a more upright, supported position when head and trunk control are impaired

For MSC: Achieve or maintain a suitable posture for hygiene

Redistribute pressure so less pressure is directed through bony prominences on the seat, if applicant is unable to weightbear in standing

Facilitate independent repositioning and transfers, and weight shifting during operation of wheelchair

Facilitate negotiations over uneven surfaces including kerbs, ramps, etc

Facilitate optimal positioning for comfort and function when deformity/pain/involuntary ,movement/abnormal tone/seizure activity are present

Manage gastro-intestinal function

Better manage respiration

Facilitate hoist transfers

11 For pressure redistribution equipment, provide evidence of pressure risk (history of pressure injuries, pressure risk assessment, ability to effectively redistribute pressure)

10 For hoists, does the applicant require (select only one that applies):

Standard spreader

4-point spreader. Reason:

Pivot frame. Reason:

12 For Mobility aids:

a) Is the applicant an existing PWC user? Yes No

If no, does the applicant have a rapidly progressing disorder? Yes No

Provide details:

Have you confirmed that the applicant’s home is PWC accessible? Yes No

b) For a specialised stroller, provide details why applicant cannot be effectively positioned in a manualwheelchair or power wheelchair or non-specialised stroller?

(Affix identification label here if available)

MASS 26Request to TrialMASS Stock Equipment

Family name:

Given name (s):

Date of Birth:

Address:

Phone Number: Sex: M F I

Second prescriber (if applicable)First prescriber

Medical Aids Subsidy Scheme(MASS) Queensland Health

Page 8 of 10

Prescriber Details

Additional Information/Comments:

13 NameTitle Family name

Given name(s)

14 Profession

15 Current registration? Yes No

16 Organisation name

17 Organisation address

Suburb / town Postcode

18 Contact detailsTelephone Fax

Mobile

Email

19 Contact hours

20 SignatureI certify that this information is in accordance with the MASS General Guidelines.

Date

21 NameTitle Family name

Given name(s)

22 Profession

23 Current registration? Yes No

24 Contact detailsTelephone Fax

Mobile

Email

25 Contact hours

26 Please list equipment you have prescribed

27 SignatureI certify that this information is in accordance with the MASS General Guidelines.

Date

(Affix identification label here if available)

MASS 26Request to TrialMASS Stock Equipment

Family name:

Given name (s):

Date of Birth:

Address:

Phone Number: Sex: M F I

� � � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � � � � � � �

� � � � � � � � �

� � ! " # $ � % & ' ! ' ( # " # & # ) � * ' + , - - # . / % 0 $ # * ' 1 # " ) % 2 # 1 ' # � $ 3 ! " 0 " ! 2 # 1 1 % * 45 " % 1 6 � * # � � 7 8 9 : 9 ; 9 < = < > ? $ � % & + , - - @ ? . / % 0 $ # * ' A ( # � & ' ( B . & C B 4 ! ) B � /D ! E * 1 ) % & & # � � 7 8 F F 9 9 G 7 7 : > ? $ � % & + , - - @ ? . / % 0 $ # * ' @ D - H A ( # � & ' ( B . & C B 4 ! ) B � /I J K L M N L K O P Q R K S T S N U V K M Q W X Y Z N S [ V \ \ K ] ] ^ V S _ Q L L K ` J ]a � b c d � e f � g � hi � j j � k � l # 1 m !n � c o p � q k e d c q � l # 1 m !a � q r � d s f � � d t f � c h l # 1 m !� � g � h s f � � d t f � c h l # 1 m !� h � o o r h � u � k c o p h c b r p c � qa � p p h � o o l # 1 m !n � v � w � r t � j x d � p � k o y c q t f � t y o p � t � q z h jo r c p � b c d c p w { l # 1 m !� h � o o r h � u � k c o p h c b r p c � qi r o f c � q l # 1 m !n � v � w � r t � j x d � p � k o y c q t f � t y o p � t � q z h jo r c p � b c d c p w { l # 1 m !| p f � h l # 1 m !

� � } ~ � � � � � � � ~ � � � � � � � � � � � � � � � } � � � � � � � � � �� � $ % & � * � $ # �� % ) # * * � $ # � 1 � �� � ' # ! 3 5 % " ' ( �, C C " # 1 1 �� ( ! * # m / $ 6 # " � � � � � � �

� Q Y ] V \ \ K ] ] ^ V S K U V Z � L K ` J �: B � 1 # . / % 0 $ # * ' � 4 ! ! C � ' 3 ! " ' ( # ( ! $ # # * ) % " ! * $ # * ' � l # 1 m != B � � * # . / % 0 $ # * ' 6 # � 0 0 " ! 0 " % � ' # & � / 1 # C > $ � % * ' � % * # C � * C 1 ' ! " # C 6 � ' ( # � 0 0 & % 2 � * ' ! "2 � " # " � l # 1 m !9 B � � 1 1 � 3 # ' � 1 E % ' 2 ( � " # 1 % C / � & 2 / " " # * ' C # ) % 2 # 6 # # * % * 1 ' � & & # C 3 ! " % ' # $ 1 2 ! * * # 2 ' # C ' !$ � % * 1 0 ! E # " 3 ! " ! 0 # " � ' % * 4 � 2 ( � " 4 % * 4 � l # 1 m ! m � ,F B � 1 ' ( # 0 " # 1 2 " % 6 # C ( ! % 1 ' 2 ! $ 0 � ' % 6 & # E % ' ( ' ( # 1 & % * 4 �� 3 * ! > 0 & # � 1 # 2 ! $ 0 & # ' # � * C 1 / 6 $ % ' ' ( # + , - - � ! % 1 ' > 1 & % * 4 2 ! $ 0 � ' % 6 % & % ' � 2 ( # 2 � & % 1 ' l # 1 m !< B , " # ' ( # " # � * � $ ! C % � 2 � ' % ! * 1 ! " � 2 2 # 1 1 ! " % # 1 " # . / % " # C � l # 1 m !� � � � � � � � � � � � � �     � ¡ ¢ � £ ¤ ¥   � � ¦ § ¨ © ª � � « ¬ © � � �   �   � ­ � ¦   ¥ � ¬ � � � ¥ ¦ � ®� Q Y V ` ] V \ \ K ] ] ^ V S K U V Z � L K ` J ¯ 0 & # � 1 # " # ' / " * ' ! + , - - B � 3 ' ( % 1 % 1 * ! ' 0 ! 1 1 % 6 & # > 2 ! * ' � 2 ' ? . / % 0 $ # * ' - # " ) % 2 # 1 ! *7 8 9 : 9 ; 9 < = F ! " # $ � % & + , - - @ ? . / % 0 $ # * ' A ( # � & ' ( B . & C B 4 ! ) B � / 3 ! " 2 ! & & # 2 ' % ! * B � 3 � ! / E � * ' ' ! # 0 & ! " # ! ' ( # " ' " % � &! 0 ' % ! * 1 > " # ) % # E ' ( # + , - - 1 ' ! 2 � & % 1 ' 1 � * C 2 ! * ' � 2 ' + , - - @ 1 ' ! 2 � A ( # � & ' ( B . & C B 4 ! ) B � / ' ! " # 1 # " ) # B� " # 1 2 " % 6 # " m � $ # �D # & # 0 ( ! * # � ? $ � % & �e c � q � p r h �@

� � ' #; B � ! * � " $ � ! / ( � ) # � " " � * 4 # C 3 ! " " # ' / " * ! 3 / * 1 / 2 2 # 1 1 3 / & # . / % 0 $ # * ' l # 1 m !© � � � � � � � � � � � � � ¬ ¥ ª © § � § �   � © � � ®

This page has been intentionally left blank

Medical Aids Subsidy Scheme, Queensland Health

Medical Aids Subsidy Scheme (MASS) staff, in accordance with the MASS Privacy Statement, are committed to maintain strict confidentiality in all aspects of service delivery. You are assured that this information will remain confidential. Your information will not be divulged without your consent, or if required or authorised by law.

Details and Eligibility confirmed: Yes No

Date: MASS Officer:

This consent will be used for the sole purpose of authorising Centrelink to provide information to MASS to access your eligibility in relation to assistance or services provided by MASS.

Applicant Confirmation:

I, authorise Centrelink to confirm with MASS the current status of my Commonwealth benefit and other details as they pertain to my concessional entitlement. This involves electronically matching details I have provided to MASS with Centrelink or Department of Veterans’ Affairs (DVA) records to confirm whether or not I am currently receiving a Centrelink or DVA benefit.

I understand this consent, once signed, is effectively only for the period I am a customer of MASS. I also understand that this consent, which is ongoing, can be revoked any time by giving notice to MASS.

I understand that if I withdraw my consent, I will need to provide a copy (both sides) of my concession card to MASS or I may not be eligible for the assistance provided by MASS.

A brochure is available from Centrelink that provides more details about the Centrelink Confirmation eServices or on Centrelink’s website at www.centrelink.gov.au

Please provide the following Commonwealth benefit card information, which must be in the name of the adult card holder/applicant. Child applicants will be required to provide a copy of their card.

Concession Card Provider (please tick): Centrelink Department of Veteran’s Affairs

Type of Concession Card (e.g. Health Care Card):

Applicant’s Concession Card Number:

Name of Card Holder:

Address on Card:

Issue Date on Card: Expiry Date on Card (if applicable):

Applicant/Carer signature: Date signed:

Post OR Fax completed forms to a MASS Service Centre

Proxy Access to Centrelink Information Formfor MASS 84This form is used for applicants, 16 years of age and over, to provide consent to MASS staff to access Centrelinkconcession card information when a photocopy of the concession card is not attached to the MASS application form

OFFICE USE ONLY

Brisbane:Medical Aids Subsidy SchemePO Box 281, Cannon Hill Qld 4170Telephone: 3136 3636 Fax: 3136 3525Email: MASS-Equipment@health.qld.gov.auWebsite: www.health.qld.gov.au/mass

Townsville:Medical Aids Subsidy SchemePO Box 980, Hyde Park Qld 4812Telephone: 4433 8000 Fax: 4433 8001Email: MASS-Equipment-TSV@health.qld.gov.au Website: www.health.qld.gov.au/mass