Information about D904 voucher (DVA request/referral)

This voucher should be used when:

  • directly referring a veteran to another health care provider
  • requesting prior financial authorisation for a treatment service for a veteran
  • requesting a rehabilitation appliance for a veteran, or 
  • requesting an hire car or taxi for a veteran.

LMOs may use their own stationery or letterhead rather than a D904 provided that all the necessary information is included and legible, such as the provider number and date of request/referral.

Note: This voucher is not available electronically but may be obtained by placing an order with the DVA warehouse.

See: Provider forms online order page

Contact

Contact DVA: Phone 1800 155 355; Fax 1800 671 670.

Sample of D904 voucher

Cover of D904 voucher
The image above is the cover information on the D904 voucher.

 

Second page of D904 voucher
The image above is the first page of the D904 voucher. The second page is a duplicate of this page.

 

Second page of the D904 voucher
The image above is the third page. The left hand side is a triplicate copy whilst the right hand side is a new section to be filled out if transport is required.

Using your own stationery

LMOs may use their own stationery or letterhead rather than a D904 provided that all the necessary information is included and legible. This includes but is not restricted to the following information:

  • veteran's name
  • veteran's DVA file number (shown on the Repatriation Health Card)
  • veteran's date of birth
  • veteran's address
  • veteran's clinical details (including recent illnesses, injuries and current medication, if applicable)
  • condition to be treated
  • description of the requested service
  • LMO's name and provider number and
  • date of referral.

For referral to any health care provider, it is the LMO's responsibility to provide the above information about a veteran to ensure that the provider understands the veteran's medical history and to allow the provider to claim payment from DVA.