Request for EMS Advice and Outcome Summary Ph: 0800 171 995 Family Name: First Names Date of birth: NHI: Client details Address: EMS Assessor details Name: AEA No.: Preferred Time/Day Preferred Contact for contact: Method: Work Phone: Mobile: Eligibility details Diagnosis: If not listed, please state: Disability/Functional loss: Resides: EMS Advice Requested Mandatory consultation Optional consultation Equipment: Housing: Vehicle: If optional consultation selected, please indicate which area(s): Eligibility Access criteria / related need Proposed solution / cost effectiveness Explanation of situation/issues Background information Click here to enter your text Click in this field and Press F1 for tips Functional limitation Click here to enter your text Click in this field and Press F1 for tips Clinical reasoning Click here to enter your text Click in this field and Press F1 for tips Proposed solution Attachments Included (where applicable) Existing sketch Eligibility for LT-CHC funding Equipment quote Proposed modification sketch Evidence of FT tertiary study Wheel or Power chair specification form Photos or Video Evidence of voluntary work Evidence of FT employment Evidence of main carer Request for EMS Advice and Outcome Summary
Request for EMS Advice and Outcome Summary Ph: 0800 171 995 Client details Family Name: First Names Date of birth: NHI: Address: EMS Assessor details Name: AEA No.: Preferred Time/Day for contact: Preferred Contact Method: Work Phone: Mobile: Eligibility details Diagnosis: If not listed, please state: Disability/Functional loss: Resides: EMS Advice Requested Mandatory consultation Optional consultation Equipment: Housing: Vehicle: If optional consultation selected, please indicate which area(s): Eligibility Access criteria / related need Proposed solution / cost effectiveness Explanation of situation/issues Background information Click here to enter your text Click in this field and Press F1 for tips Functional limitation Click here to enter your text Click in this field and Press F1 for tips Clinical reasoning Click here to enter your text Click in this field and Press F1 for tips Proposed solution Attachments Included (where applicable) Existing sketch Equipment quote Evidence of FT tertiary study Photos or Video Evidence of FT employment Eligibility for LT-CHC funding Proposed modification sketch Wheel or Power chair specification form Evidence of voluntary work Evidence of main carer Request for EMS Advice and Outcome Summary
Request-for-EMS-Advice.docx