Application For Additional Stoma Supplies
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1
2
3Application for additional
stoma supplies
3
Purpose of this form
Medicare card number
Use this form to apply for additional stoma supplies under the Stoma
Ref no.
Appliance Scheme.
or
This certificate is valid for up to 6 months.
Department of Veterans’ Affairs card number
For more information
4
Stoma Appliance Scheme entitlement number
For more information about the Stoma Appliance Scheme, go to our
humanservices.gov.au or if you need assistance
website
www.
completing this form, call 1800 700 270 Monday to Friday, between
8.30 am and 5.00 pm, Australian Eastern Standard Time.
Stoma association’s details
Note: Call charges apply from mobile phones.
5
Stoma association name
Filling in this form
•
Please use black or blue pen
•
Print in BLOCK LETTERS
6
Stoma association approval number
✓
7
•
Mark boxes like this
with a
or
Returning your form
Additional supplies requested
Check that you have answered all the questions you need to answer
7
and that you have signed and dated this form.
Additional product 1
SEND THIS FORM TO YOUR NOMINATED STOMA ASSOCIATION
Product name
FOR PATIENT REGISTRATION.
The nominated Stoma Association will send the completed form to:
SAS code
Manufacturer code
Department of Human Services
Stoma Appliance Scheme
SAS allowance
Additional quantity required
GPO Box 9826
HOBART TAS 7001
Period required
Commencing month/year
Applicant’s details
1
Dr
Mr
Mrs
Miss
Ms
Other
Additional product 2
Family name
Product name
First given name
SAS code
Manufacturer code
Second given name
SAS allowance
Additional quantity required
2
Period required
Commencing month/year
Address
If additional products are required, attach a separate
Postcode
sheet with details.
1 of 3
PB050.1510
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Parent category: Business