Community Nursing Second Worker Form
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1IMPORTANT
Community Nursing
Second Worker Form
Privacy notice
Your personal information is protected by law, including the Privacy Act 1988. Your personal information may be collected by
the Department of Veterans’ Affairs (DVA) for the delivery of government programs for war veterans, members of the Australian
Defence Force, members of the Australian Federal Police and their dependants.
Read more: How DVA manages personal information.
Purpose of this form
This form is for situations where two workers are required at the same visit(s) in a 28 day period. It should be submitted to the
Exceptional Case Unit (ECU) for a prior approval to be processed. This form is NOT a claim for exceptional case status.
Submitting the form:
The preferred method is via DVA’s secure email. Please contact the ECU on: 1800 636 428 to register for this option.
About Sensitive email:
Part A - Community Nursing Provider Information
1.
Provider name
2.
Provider number (site if applicable)
Part B - Entitled Person Information
3.
DVA file number
4.
Surname
5.
Given name(s)
6.
Date of birth
/
/
Part C - Second Worker Information
7.
Commencement date for the
Note: This date must match the claiming date of the
relevant 28-day claim period
/
/
core item.
covered by this application
8.
Schedule of Fees Item Number
claimed (compulsory)
9.
Is second worker required on an
No
Yes
ongoing basis?
10. Reason why second worker is
required
11. Second worker
RN Visits
EN Visits
NSS Visits
(Visits and hours/minutes relate
RN Hours/
EN Hours/
NSS Hours/
to the total in the 28-day claim
minutes
minutes
minutes
period)
Part D - Declaration
I declare that the information I have supplied on this form is true and correct.
12. Name
[
]
13. Phone number
Date
14. Signature
/
/
D1391 0115 P1 of 1
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