Provider forms
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Use these forms to arrange treatment and support services for veterans and their dependents who have DVA health cards.
Healthcare professionals seeking further information about DVA health arrangements and programs please visit the DVA providers page.
If you need assistance with DVA forms, call us on 1800 555 457.
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Displaying 83 forms| Form ID | Title | Audience |
|---|---|---|
| D9353 | D9353 Activities of daily living assessment | For providers, Occupational therapist (general) |
| D9076 | D9076 Acute Care Certificate | For providers, Hospitals & day procedure centres |
| D0695 | D0695 Allied health time based voucher | For providers, Chiropractor, Diabetes educator, Dietitian, Exercise physiologist, Medical specialist, Neuropsychologist, Occupational therapist (general), Occupational therapist (mental health), Optometrist, Orthoptist and Optical dispenser, Orthotist, Osteopath, Physiotherapist, Podiatrist/Footwear prescriber, Psychologist, Social worker (general), Social worker (mental health), Speech pathologist |
| D1004 | D1004 Application for Community Nursing Exceptional Case Status | For providers, Community nursing, Registered Nurse |
| D9208 | D9208 Application for Licence to Reproduce Department of Veterans' Affairs Card Images | For providers, Pharmacist |
| D1206 | D1206 Application for Provider Registration for an Orthoptist | For providers, Optometrist, Orthoptist and Optical dispenser |
| D9173 | D9173 Application to list or modify price of a product on the RSPB | For providers, Pharmacist |
| D1004A | D1004A Attachment 1 Exceptional Case – Dementia / Short Term Memory Loss / Confusion | For providers, Community nursing, General |
| D1004B | D1004B Attachment 2 Exceptional Case — Mental Health | For providers, Community nursing |
| D1004C | D1004C Attachment 3 Exceptional Case — Palliative Care | For providers, Community nursing |
| D1004D | D1004D Attachment 4 Exceptional Case — Wound Care | For providers, Community nursing |
| D9398 | D9398 Audiology prior financial approval request | For providers, Audiologist, Audiometrist, Otolaryngologist |
| D9294 | D9294 Chiropractic/Osteopathy/Physiotherapy Prior Financial Approval Request | For providers, Chiropractor, Osteopath, Physiotherapist |
| D9401 | D9401 Claim for assistance dog expenses | General, For providers |
| D1217CN | D1217CN Claim for Treatment Services - Community Nursing | For providers, Community nursing |
| D1217 | D1217 Claim for treatment services voucher | General, For providers, Chiropractor, Clinical psychologist, Dental prosthetist, Dental specialist, Dentist, Diabetes educator, Dietitian, Exercise physiologist, General Practitioner, Hospitals & day procedure centres, Medical specialist, Neuropsychologist, Occupational therapist (general), Optometrist, Orthoptist and Optical dispenser, Orthotist, Osteopath, Physiotherapist, Podiatrist/Footwear prescriber, Psychologist, Social worker (mental health), Speech pathologist |
| D9389 | D9389 Community Nursing Referral | For providers |
| D1083 | D1083 Community Nursing Service Voucher | For providers, Community nursing |
| D6345 | D6345 Coronary Care Patient Certificate | Registered Nurse, For providers, Hospitals & day procedure centres, Medical specialist |
| D0804 | D0804 D0804 - Home Medical Oxygen Therapy and/or Respiratory Home Therapy Appliances form | For providers, General Practitioner, Hospitals & day procedure centres, Medical specialist, Physiotherapist, Registered Nurse |
| D0904 | D0904 D0904 - DVA request/referral voucher | For providers, General Practitioner |
| D0988 | D0988 D0988 – Continence direct order form | For providers, General Practitioner, Medical specialist, Occupational therapist (general), Occupational therapist (mental health), Physiotherapist, Registered Nurse |
| D0992 | D0992 D0992 - Mobility Functional Support (MFS) products order form | For providers, General Practitioner, Hospitals & day procedure centres, Medical specialist, Occupational therapist (general), Physiotherapist, Rehabilitation service provider, Registered Nurse, Exercise physiologist, Podiatrist, Orthotist, Prosthetist |
| D1323 | D1323 D1323 - Authority to Install/Modify - Home/Access Modifications | For providers, Occupational therapist (general) |
| D1325 | D1325 D1325 - Electric Mobility Aids - Part 2 - Assessment | For providers, Occupational therapist (general) |
| D1327 | D1327 D1327 – Complex Home/Access Modifications | For providers, Occupational therapist (general) |
| D1382 | D1382 D1382 - Request for assistive communication device and/or speech pathology apps/software | For providers, Medical specialist, Speech pathologist |
| D9140 | D9140 D9140 - Application for Positive Airways Pressure (PAP) Equipment | For providers, Hospitals & day procedure centres, Medical specialist |
| D9160 | D9160 D9160 - Request for Trial of Equipment (Exercise Bike/Knee Scooter) - 3 Months Only | For providers, Chiropractor, Exercise physiologist, General Practitioner, Medical specialist, Osteopath, Physiotherapist |
| D9199 | D9199 D9199 - Assessment form for the supply of a Personal Response System | For providers, General Practitioner, Medical specialist, Occupational therapist (general), Physiotherapist, Registered Nurse |
| D9257 | D9257 D9257 - Order form for low vision products | For providers, Hospitals & day procedure centres, Medical specialist, Occupational therapist (general), Optometrist, Orthoptist and Optical dispenser, Registered Nurse |
| D9299 | D9299 D9299 - Post Home Modification Report | For providers, Occupational therapist (general) |
| D9300 | D9300 D9300 - Electric Mobility Aids - Part 1 - Medical Assessment | For providers, General Practitioner |
| D9356 | D9356 D9356 - Request for an assistance dog | For providers, Clinical psychologist, Medical specialist, Neuropsychologist, Occupational therapist (general), Occupational therapist (mental health), Psychologist, Social worker (mental health) |
| D9376 | D9376 D9376 - Request for assistive listening devices and/or tinnitus devices | For providers, Audiologist, General Practitioner, Hospitals & day procedure centres, Rehabilitation service provider, General |
| D9379 | D9379 D9379 - Electric Mobility Aids - Part 3 - Trial | For providers, Occupational therapist (general) |
| D9381 | D9381 D9381 - Authority to Install/Modify - Vehicle Modifications | For providers, Occupational therapist (general) |
| D9414 | D9414 D9414 - Order Form Diabetes Products | General Practitioner, Diabetes educator, Diabetes Clinic, Endocrinologist, Registered Nurse, Specialist (includes all medical specialists in relevant field), For providers |
| D9416 | D9416 D9416 - Disfigurement and Social Impairment Medical Impairment Assessment | For providers, Compensation provider |
| D9417 | D9417 D9417 - Ear Condition Medical Impairment Assessment | For providers, Compensation provider |
| D9418 | D9418 D9418 - ADLs / Functional Impact Medical Impairment Assessment | For providers, Compensation provider |
| D9419 | D9419 D9419 - Hearing Loss and Tinnitus Medical Impairment Assessment | For providers, Compensation provider |
| D9420 | D9420 D9420 - Intermittent Condition(s) Medical Impairment Assessment | For providers, Compensation provider |
| D9421 | D9421 D9421 - Treatment, Aggravations & Historic Injuries Medical Impairment Assessment | For providers, Compensation provider |
| D9422 | D9422 D9422 - Upper Respiratory Tract Medical Impairment Assessment | For providers, Compensation provider |
| D0919 | D0919 Dental report and voucher | For providers, Dental prosthetist, Dental specialist, Dentist |
| D0986 | D0986 Dental Request for Prior Approval for Treatment or Referral to a Specialist | For providers, Dental prosthetist, Dental specialist, Dentist, Medical specialist |
| D9287 | D9287 Diagnosis Form | For providers |
| D0653A | D0653A Discharge Advice and Hospital Claim | For providers, Hospitals & day procedure centres |
| D9132 | D9132 Dose Administration Aid (DAA) service VSMR | For providers, Pharmacist |
| D9367 | D9367 DVA work trial agreement | For providers, Rehabilitation service provider |
| D9400 | D9400 Essential Medical Equipment Payment (EMEP) claim | General, For providers |
| D9384 | D9384 Exceptional Case Interruption to Care | For providers, Registered Nurse |
| D9297 | D9297 Exceptional Case Unit - Request for Reimbursement of Nursing Consumables over $1,000 | For providers |
| D1307 | D1307 Exceptional Case Variation | Registered Nurse, For providers |
| D1221 | D1221 Health practitioner service voucher | General, For providers |
| D0652B | D0652B Hospital Admission Voucher | For providers, Hospitals & day procedure centres |
| D6346 | D6346 Intensive Care Patient Certificate | Registered Nurse, For providers, Hospitals & day procedure centres, Medical specialist |
| D9283 | D9283 Job Seeking Questionnaire | For providers, Rehabilitation service provider |
| D9291 | D9291 Medical Disclosure Authority (multiple practitioners) | For providers, General Practitioner, Hospitals & day procedure centres, Medical specialist, Rehabilitation service provider |
| D9290 | D9290 Medical Disclosure Authority (single practitioner) | For providers, General Practitioner, Hospitals & day procedure centres, Medical specialist |
| D0688 | D0688 Medical grade footwear (MGF) prescription form | For providers, Orthotist, Podiatrist/Footwear prescriber |
| D9403 | D9403 Medicinal Cannabis Tier 2 Application | For providers, General Practitioner, Medical specialist, Specialist (includes all medical specialists in relevant field) |
| D9292 | D9292 MRI/PET Scan Prior Financial Approval Request form | For providers, Hospitals & day procedure centres, Medical specialist |
| D1372 | D1372 Optical dispensing registration form | For providers, Medical specialist, Optometrist, Orthoptist and Optical dispenser |
| D1399 | D1399 Optical treatment prior financial approval request | For providers, Optometrist, Orthoptist and Optical dispenser |
| D1223 | D1223 Optometric, optometry and optical service voucher | General, For providers, Optometrist, Orthoptist and Optical dispenser, Optometrist |
| D9352 | D9352 Orthotist prior financial approval request form | For providers, Orthotist |
| - | - Outreach Program Counsellor (OPC) statutory registration form | For providers, Clinical psychologist, Psychologist, Social worker (mental health) |
| D1218 | D1218 Pathology service voucher | General, For providers |
| D9314 | D9314 Prior Approval Request for Treatment of Alcohol and Other Drug Use (AOD) | For providers, Clinical psychologist, Hospitals & day procedure centres, Medical specialist, Neuropsychologist, Psychologist, Social worker (mental health) |
| D1347 | D1347 Rehabilitation Plan | For providers, Rehabilitation service provider |
| D9323 | D9323 Request for Prior Approval for Dental Implants | For providers, Dental prosthetist, Dental specialist, Dentist, Hospitals & day procedure centres, Medical specialist |
| D9284 | D9284 Retraining Questionnaire | For providers, Rehabilitation service provider |
| D0570 | D0570 Service Pension Claim - Work Test Questionnaire | For providers |
| D0931 | D0931 Spectacles prescription | For providers, Optometrist, Orthoptist and Optical dispenser |
| TFI01 | TFI01 Tinnitus Functional Index Questionnaire and Scoring Instructions | For providers, Audiologist |
| D1328 | D1328 Treatment prior financial approval request | For providers, Chiropractor, Clinical psychologist, Dental prosthetist, Dental specialist, Dentist, Diabetes educator, Dietitian, Exercise physiologist, General Practitioner, Hospitals & day procedure centres, Medical specialist, Neuropsychologist, Occupational therapist (general), Optometrist, Orthoptist and Optical dispenser, Orthotist, Osteopath, Physiotherapist, Podiatrist/Footwear prescriber, Psychologist, Social worker (mental health), Speech pathologist |
| D1216 | D1216 Treatment service voucher | General, For providers, General Practitioner |
| D1216G | D1216G Treatment service voucher (for use by general practitioners only) | General, For providers, General Practitioner |
| D1216S | D1216S Treatment service voucher (for use by specialists and consultant physicians only) | General, For providers, Physiotherapist, Continence Adviser (Registered nurse or Physiotherapist Continence Adviser), Exercise physiologist |
| D9388 | D9388 Veteran Health Check Assessment Tool | For providers |
| D1338 | D1338 Vietnam Veterans' Sons and Daughters Support Program (VVSDSP) - prior approval form | General, For providers, Chiropractor, Clinical psychologist, Dental prosthetist, Dental specialist, Dentist, Dietitian, Exercise physiologist, General Practitioner, Hospitals & day procedure centres, Medical specialist, Neuropsychologist, Occupational therapist (general), Occupational therapist (mental health), Optometrist, Orthoptist and Optical dispenser, Orthotist, Osteopath, Physiotherapist, Podiatrist/Footwear prescriber, Psychologist, Social worker (general), Social worker (mental health), Speech pathologist |