<p> Equipment Program Checklist for Seeking Delegate Approval Equipment</p><p>From DES website July 2013</p><p>Is the equipment type requested on the “Equipment in-scope list” ? Y / N If No, have all possible in scope items been trialled with client and found unsuitable? Y / N Equipment items and features not in scope will not be supplied by the Equipment Program. Discuss any exceptional circumstances with delegate to identify alternative solutions. For all other equipment requests: Does the requested item meet the “Key approval criteria for equipment” ? Y / N</p><p>Specific eligibility criteria exist for selected Category 2 equipment. Is client eligible? Y / N See “Criteria” items on DES website</p><p>Eligibility screening is required for selected Category 2 equipment. Is this complete? Y / N See “Criteria screening tools” items on DES website</p><p>Do you have approved prescriber status for the equipment type (or has the prescription Y / N been supervised by an approved prescriber)?</p><p>Have all simpler equipment/non equipment options been trialled/explored with client? Y / N</p><p>If second item of same equipment type requested, does need meet key approval criteria? Y / N</p><p>Is the priority rating given appropriate for the client’s needs/situation? Y / N</p><p>If the item is Cat 2, have all Cat 1 items been considered/trialled? Y / N</p><p>If high risk/cost item approved has delegate signed provisional approval on the Prescription Y / N Agreement Form (or quote if outsourced request)? </p><p>Once decision has been made  Approved: Delegate signs the prescription form & prescriber notes in client’s file. If verbal/email approval of online order insert delegate’s name.  Provisional Approval: If quotation is required for purchase of high risk or high cost item, additional delegate approval on the quotation is required  Not approved: Complete client advice letter and forward to delegate for signing. </p><p>Equipment Program: Telephone:1300 295 786 Fax:1300 295 839 Email: [email protected]</p><p>Page 1 of 1 </p>