Activity Level K0 K1 K2 K3 K4 Not required for upper extremity Date Signature of Prescriber Prescriber Number Prescriber Name EnableNSW Authorisation Prosthetic Service Provider to complete blanks Prosthetic Service Provider: This consumer is eligible for provision of service through EnableNSW _____________________________ This consumer is eligible for provision of service through the DVA EnableNSW has approved Standard components from Contract 980B Cast Date Trial Date EnableNSW has approved Non-Standard components from Contract 980B as itemised below EnableNSW has approved Non-Contract components as itemised below LIMB NO: __________________________ Type of Limb: ___________________________________ EnableNSW Authorisation Date ____________________ __________ Non-Standard Components used in this prosthesis paid Prosthetic User Acceptance for by the prosthetic user: I certify that I have received the limb referred to in this prescription. Signature of prosthetic user Date Signature of Provider Date
Activity Level K0 K1 K2 K3 K4 Not required for upper extremity Signature of Prescriber Date Prescriber Name Prescriber Number EnableNSW Authorisation This consumer is eligible for provision of service through EnableNSW This consumer is eligible for provision of service through the DVA EnableNSW has approved Standard components from Contract 980B EnableNSW has approved Non-Standard components from Contract 980B as itemised below EnableNSW has approved Non-Contract components as itemised below LIMB NO: __________________________ Type of Limb: ___________________________________ EnableNSW Authorisation Date ____________________ __________ Prosthetic Service Provider to complete blanks Prosthetic Service Provider: _____________________________ Cast Date Trial Date Prosthetic User Acceptance I certify that I have received the limb referred to in this prescription. Signature of prosthetic user Date Non-Standard Components used in this prosthesis paid for by the prosthetic user: Signature of Provider Date
Interim-Prosthesis-form-20180416.docx