Submit for Approval / Supply For existing Disability SA clients All other clients ASSIST therapists Submit to Submit to All other therapists Submit to ASSIST Use Only File no. Approved prescriber Name Signed Date (if not as above) ELC Name Signed Date Delegate Name Signed Date DES Internal Use Only Confirmed funding Stream DSA APER ACC GF Customised Mobility CoS > 65s Delegate Name Signed Date
Submit for Approval / Supply For existing Disability SA clients ASSIST therapists Submit to All other therapists Submit to All other clients Submit to ASSIST Use Only File no. Approved prescriber (if not as above) Name Signed Date ELC Name Signed Date Delegate Name Signed Date DES Internal Use Only Confirmed funding Stream DSA APER ACC GF Customised Mobility CoS > 65s Delegate Name Signed Date
Equipment%20Request%20Form%20-%20DHS%20Equipment%20Program.docx