Old MJM Referral Form

CHSP Major Modifications Referral Form
Type of Mods Referral
If you require items to be quoted separately please submit separate referrals for each item.
Did you receive this referral from Home Assist Community Services
Enquiry Number (EN on OT Job Sheet)
- Consumer Details
- Title
- Full Name
- Date Of Birth
  
  DayMonthYear
- Street Address
- Suburb and Postcode
- Postal Address (if different from above)
- Suburb and Postcode
- Phone
- Mobile
- E-Mail
- Please note to be eligible for CHSP Home Modifications funding consumers need to be registered and have a My Aged Care Referral Code for Home Modifications.
  
  Please advise consumer to contact My Aged Care (1800 200 422) if they do not have a Home Modifications Referral Code and contact Home Assist Community Services on (07) 4123 2234 with their Code so we can assist them with CHSP funding and avoid delays.
- Is the Consumer Registered with My Aged Care?
- Referral Code for Home Modifications (if available)
- Additional Contact Person
- Relationship to Client
- Phone
- Mobile
- Dwelling Details
- Residency Type
- Owner / Landlord / Agency Name
- Owner / Landlord / Agency Email
- Phone
- Please verify that you are human
- Consumers Diagnosis/Medical Condition
- Aids already in place
  
  Other
- Type of Modification
  
  Other
- Description of problems experienced in the area to be modified?
- Benefits of modification request?
- Any Additional Information?
- Priority
- Discharge from hospital dependent on completion of Home Modifications?
- Planned Discharge Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Does Occupational Therapist need to be present at Builders Assessment?
- Preferred Builder/Contractor?
- Please be advised Builders will need to be QBCC Registered, have public liability insurance, police check and be willing to become registered with Home Assist Community Services.
- Preferred Builder/Contractor Phone Number?
- Diagrams / Drawings / Photos Attached
  
  Cancelof
- *Please note - Video Assessment and OT Proforma are no longer a requirement.
- The modification/s requested have been clinically recommended for continued safety and independence.
- Prescribing Occupational Therapist's Name
- Occupational Therapist's Organisation
- Occupational Therapist's Phone
- Occupational Therapist's Email
  example@example.com
- Occupational Therapist's Signature
- Submission Date
  
  DayMonthYear
  2 digit day, 2 digit month, 4 digit yearDate
- $125.00 Inc GST Fee for Service applies. Included is one Home Assessment by the Home Assist Community Services builder with Occupational Therapist. One Floor Plan (this allows for one revision of the floor plan only)
- Quotes are only valid for 30 days. All work requested has been discussed with and has the consent of the consumer and/or their career. Consumer is aware of the $100.00 cancellation fee should the requested work not proceed or if the referral is cancelled 24 hours after submission. Cancellation fee also applies if quote expires
- Home Care Package Level
- Home Care Package Provider
- Provider Email Address
  example@example.com
- Provider Case Manager
- Provider Phone Number
- Email For Quotes (if different from above)
  example@example.com
- Email For Tax Invoices (if different from above)
  example@example.com
- Is a Site ID required for invoicing purposes?
- Site ID Number
- Is a Purchase Order / Service Request Form required?
- Upload Purchase Order / Service Request (if avaiable)
  
  Cancelof
- Type of Modification
  
  Other
- Home Care Package Budget Allowance for Modification
  (this is requested, so the budget can be taken into consideration in the design)
- Priority Rating for Completion of Work
- Work Requested
- Diagrams / Drawings / Photos Attached
  
  Cancelof
- All work requested has been discussed with and has the consent of the client and their Home Care Package Provider. Client and Home Care Package Provider are aware and accept the fees outlined above.
- Occupational Therapist's Name
- Occupational Therapist's Organisation
- Occupational Therapist Phone Number
- Occupational Therapist Email Address
  example@example.com
- Does Occupational Therapist need to be present at Builders Assessment?
- Occupational Therapist's Signature
- Submission Date
  
  DayMonthYear
  2 digit day, 2 digit month, 4 digit yearDate
- Should be Empty:

CHSP Major Modifications Referral Form

If you require items to be quoted separately please submit separate referrals for each item.

Consumer Details