Life Support Concession Application Form State Revenue Office
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2State Revenue Office
Department of Treasury and Finance
Life Support Concession
The Life Support Concession provides a daily discount to eligible customers who use an approved life support system or who live with
someone who uses such a system.
Electricity account holder’s details
First Names
Surname
Residential Address
Suburb/Town
Postcode
Postal Address (if different from above)
Suburb/Town
Postcode
Home Phone No.
Mobile Phone No.
Signature
Date
/
/
Electricity retailer’s details
Electricity Retailer
NMI No. (if known)
Account No.
(see back of page)
Patient’s details
First Names
Surname
Residential Address
Suburb/Town
Postcode
If your medical practitioner approves a machine for you that is not on the list below, please contact the State Revenue Office
with the details by emailing concessions@treasury.tas.gov.au or phoning (03) 6166 4400 or 1800 001388 (for Tas-based callers
outside the '62' area).
Medical Practitioner to complete this section
The applicant has the following type(s) of machine (please )
Oxygen concentrator
Haemo-dialysis machine
Chronic positive pressure and airways regulator
Respirator (iron lung)
Combination oxygen concentrator chronic
Phototherapy machine
positive pressure and airways regulator
Peritoneal dialysis machine
Left ventricular assist device
If your patient’s machine does not appear on the list above, please add it here.
Other:
Practitioner’s name
Position
Telephone
AHPRA No.
Signature
Date
/
/
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