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.

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.