Form D1019 - Exceptional Case Status Or Second Worker Notification Of Interruption To Care Form
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1IMPORTANT
Exceptional Case Status or Second Worker
Noti cation of Interruption to Care
Telephone: 1800 636 428
This form is used to notify the Exceptional Case Unit (ECU) of a client’s interruption to care, discharge from or
death during an agreed period of exceptional case status or second worker. All information should be completed
Facsimile: (02) 6289 6682
in black or blue pen. The noti cation must be submitted within fourteen (14) days of the date of interruption to
Secure e-mail. Please contact the
care.
ECU on: 1800 636 428 to register
If the client has been absent from care for more than 28 days, for whatever reason, they must be discharged from
for this option.
community nursing care.
About Secure e-mail:
The completed form should be submitted to the ECU by fax or secure email. If you require any assistance in
completing this form please telephone the ECU on 1800 636 428.
sensitive-emails
Please note that if a client has an interruption to care during an agreed period of exceptional case status, the ECU
may adjust the fee paid for the 28-day claim period during which the interruption to care occurred.
Client details
Client’s DVA File Number
Surname
Given name(s)
Service provider name
Provider site (if applicable)
Provider details
Service provider number
Please mark the appropriate
Date service
Total number
Date interruption
Was the client
box and provide the relevant
resumed
of visits not
to care
visited on this
information:
Reason for interruption to care
(if applicable)
attended
commenced
day?
Return to self care/discharge
/
/
Yes
No
/
/
Admitted to hospital
/
/
Yes
No
/
/
Transferred to another provider
/
/
/
/
Yes
No
Admitted to respite
/
/
Yes
No
/
/
Admitted to permanent residential care
/
/
Yes
No
/
/
Admitted to hospice
/
/
Yes
No
/
/
/
/
/
/
Deceased
Yes
No
/
/
/
/
Schedule Fee - Item number
Yes
No
/
/
Yes
No
/
/
Other - please specify
Please note the Department may use this information as part of the provider performance monitoring
process.
Privacy notice
The person completing this form is responsible for ensuring that the client is aware that the:
•
client’s personal information will be forwarded to the ECU for determining bene ts under the Veterans’
Entitlements Act 1986 and/or the Military Rehabilitation and Compensation Act 2004;
•
information, in certain circumstances, may be used for review or audit purposes or be disclosed to the
client’s Local Medical Of cer (LMO), General Practitioner (GP), Specialist or other health professional; and
•
information will be treated in a con dential manner.
Name
Signature
Designation
Date
/
/
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