Rehab at Home Extension request

Instructions

Use this form to request the extension of rehabilitation at home services for a TAC client. Complete only if you have registered with the TAC to deliver these services.

Required fields are marked with an asterisk (*).

Provider details

Clinician name *

Clinic name

Billing number

Provider address *

Provider suburb *

Provider postcode *

Provider email * (this email is used to provide the link if you use the save and exit option)

Provider phone *

Days/hours available

TAC client details

First name *

Last name *

TAC claim number *

Date of accident *

Date of birth *

Date of TAC referal *

Estimated RAH extension start date *

Estimated RAH extension end date *

Primary injury for rehabilitation/treatment

Injury Type *

Side of Body *

Location *

Specific location * (e.g. thumb, 1-2 vertebrae)

Additional injury for rehabilitation/treatment

Injury Type

Side of Body

Location

Specific location (e.g. thumb, 1-2 vertebrae)

Other injury for rehabilitation/treatment

Injury Type

Side of Body

Location

Specific location (e.g. thumb, 1-2 vertebrae)

Pre-existing co-morbidities

Arthritis
Cancer
Cardiac disease
Chronic pain
Dementia
Diabetes
Mental health
Neurological condition
Obesity
Renal failure
Respiratory disease

if other (please specify)

Goals and outcome measures

EQ-5D-5L scores

Mobility *

Self-care *

Usual activities *

Pain/discomfort *

Anxiety and depression *

Rehabilitation goals

Rehabilitation goal 1

Rehabilitation goal *

Current State *

Expected Outcome

Reason for delay

Rehabilitation goal 2

Rehabilitation goal

Current State

Expected Outcome

Reason for delay

Rehabilitation goal 3

Rehabilitation goal

Current State

Expected Outcome

Reason for delay

Rehabilitation goal 4

Rehabilitation goal

Current State

Expected Outcome

Reason for delay

Rehabilitation goal 5

Rehabilitation goal

Current State

Expected Outcome

Reason for delay

Outcome measures

Measurable goals e.g. attend local shops by increasing walking distance
Measurable tool e.g. six-minute walk
Current Measurable score e.g. 100m

Goal 1

Measurable goals (e.g. attend local shops by increasing walking distance)

Measurable tool

Current measurable score

Current measurable date

Discipline addressing each goal *

Goal 2

Measurable goals

Measurable tool

Current measurable score

Current measurable date

Discipline addressing each goal

Goal 3

Measurable goals

Measurable tool

Current measurable score

Current measurable date

Discipline addressing each goal

Goal 4

Measurable goals

Measurable tool

Current measurable score

Current measurable date

Discipline addressing each goal

Goal 5

Measurable goals

Measurable tool

Current measurable score

Current measurable date

Discipline addressing each goal

Details for extensions

Clinical justification for the provision of rehabilitation at home and why needed over community-based services

Extension timeframe *

Frequency/type of services being requested

Therapy 1

Therapy

1/2 hour sessions per day

Number of days per week

Number of weeks

Total Sessions

Therapy 2

Therapy

1/2 hour sessions per day

Number of days per week

Number of weeks

Total Sessions

Therapy 3

Therapy

1/2 hour sessions per day

Number of days per week

Number of weeks

Total Sessions

Therapy 5

Therapy

1/2 hour sessions per day

Number of days per week

Number of weeks

Total Sessions

Therapy 4

Therapy

1/2 hour sessions per day

Number of days per week

Number of weeks

Total Sessions

Expected progress with extension against client's rehabilitation goals

Rehabilitation goal 1

Rehabilitation goal

Current State *

Expected progress

Rehabilitation goal 2

Rehabilitation goal

Current State

Expected progress

Rehabilitation goal 3

Rehabilitation goal

Current State

Expected progress

Rehabilitation goal 4

Rehabilitation goal

Current state

Expected progress

Rehabilitation goal 5

Rehabilitation goal

Current state

Expected progress

If ‘other’ selected for a reason for delay, please provide details.

Expected progress with extension against client's outcome measures

Goal 1

Measurable goals (e.g. attend local shops by increasing walking distance)

Measurable tool

Current measurable score

Current measurable date

Discipline addressing each goal *

Goal 2

Measurable goals

Measurable tool

Current measurable score

Current measurable date

Discipline addressing each goal

Goal 3

Measurable goals

Measurable tool

Current measurable score

Current measurable date

Discipline addressing each goal

Goal 4

Measurable goals

Measurable tool

Current measurable score

Current measurable date

Discipline addressing each goal

Goal 5

Measurable goals

Measurable tool

Current measurable score

Current measurable date

Discipline addressing each goal

Signature

Signature *

Privacy

The TAC will retain the information provided and may use or disclose it to make further inquiries to assist in the ongoing management of the claim or any claim for common law damages. The TAC may also be required by law to disclose this information. Without this information, the TAC may be unable to determine entitlements or assess whether the treatment is reasonable and may not be able to approve further benefits and treatment. If you require further information about our privacy policy, please call the TAC on 1300 654 329 or visit our website at www.tac.vic.gov.au