D0904 - DVA request/referral voucher
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Form file format
Download as PDF (143.53 KB)
Form ID
D0904
Audience
For providers
General Practitioner

Use this form to request referral of a DVA client to another health service provider. May be referred to as D0904 or D904.

If you are using an Apple computer and want to fill out your form electronically, please download the form and open it with Acrobat 7 or later.

How to use this DVA Referral Template form 

This template is designed to help health care providers refer a DVA client to another health care provider.

You don’t have to use this exact template, but your referral must include all the information listed below to meet DVA requirements.  

This form does not need to be sent to DVA once completed.

Referrals for Allied Health Services 

A referral is required for a DVA client to receive DVA funded allied health services, except for optical and dental treatment. A referral to an allied health service is valid for one treatment cycle. For more information refer to the Notes for GPs.   

Other Referrals  

GPs may refer entitled persons to public community support services, medical specialists, and to other health care providers for treatment.

For more information refer to the Notes for GPs.   

Referral information requirements 

  • Client’s full name and DVA file number (as shown on their DVA Veteran Card) 
  • Their treatment entitlement: Gold Card or White Card (list accepted conditions for White Card holders) 
  • Your name and provider number 
  • Confirmation that you are the client’s usual GP, a medical specialist, or a health professional involved after a hospital discharge 
  • Date of referral 
  • If the client lives in a Residential Aged Care Facility (RACF), include the RACF name 
  • The client’s clinical details (such as recent illnesses, injuries, and current medication, if relevant) 
  • The medical condition(s) to be treated or the reason for referral (e.g. “Osteoarthritis of right knee”, not “Rehabilitation”) 
  • Names of other health care providers treating the client   

When to Use This Form 

  • To refer a DVA client directly for treatment services 
  • To refer directly to another provider when DVA prior approval is not needed

For more details about DVA’s requirements or to check if prior approval is needed, see the booklet ‘Notes for GPs’ and ‘Notes for Allied Health Providers – Section One – General’, 

Important

  • The treating health care provider is responsible for confirming the client’s eligibility for DVA-funded treatment. 
  • White Card holders can only receive DVA-funded treatment for their accepted conditions. 
  • If you make a bulk referral, send any clinical details directly to the provider. 
  • If you are referring a chronically ill patient to a medical specialist and an indefinite referral is suitable, write “ind” for the referral period. (Not applicable for Allied Health Providers – see Treatment Cycle information on pg 2 of this form). 
  • DVA will not cover costs if prior approval is needed but not obtained, if ineligible clients are treated, or if treatment is provided by someone not authorised by DVA.