user guide – travel referral (form b) · user guide – travel referral (form b) queensland...

User guide – Travel referral (Form B) Queensland Health Use this step-by-step-guide to the Travel referral (Form B) to apply for the Patient Travel Subsidy Scheme (PTSS). Parts of this form need to be completed by the clinician referring the patient. Information provided in this form will be used to determine the patient’s eligibility for PTSS and their subsidy amount. To update personal details the Patient registration (Form A), needs to be filled out. Please provide the patient’s personal details. 1 Section A This section needs to be completed by the clinician referring the patient. All fields need to be completed. The medical condition section should also include any special conditions which may impact or influence where the patient receives treatment. 2 3 Section B Clinical reason for selected mode of travel is important to complete if the patient’s travel is restricted such as mobility, disability, health condition etc. This section needs to be completed by the clinician referring the patient. Providing more information will help a more informed decision to be made. 5 4 Section C To register or update a patient’s personal details please use the Patient registration (Form A). To confirm patient attendance at an appointment please fill out the Appointment attendance (Form C).

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User guide – Travel referral (Form B)

Queensland Health

Use this step-by-step-guide to the Travel referral (Form B) to apply for the Patient Travel Subsidy Scheme (PTSS). Parts of this form need to be completed by the clinician

referring the patient. Information provided in this form will be used to determine the patient’s eligibility for PTSS and their subsidy amount.

To update personal details the Patient registration (Form A), needs to be filled out.

Please provide the patient’s personal details.

Sect

ion

This section needs to be completed by the clinician referring the patient.

All fields need to be completed.

The medical condition section should also include any special conditions which may impact or influence where the patient receives treatment.

Sect

ion

Clinical reason for selected mode of travel is important to complete if the patient’s travel is restricted such as mobility, disability, health condition etc.

This section needs to be completed by the clinician referring the patient. Providing more information will help a more informed decision to be made.

Sect

ion

To register or update a patient’s personal details please use the Patient registration (Form A). To confirm patient attendance at an appointment please fill out the Appointment attendance (Form C).

Page 2: User guide – Travel referral (Form B) · User guide – Travel referral (Form B) Queensland Health Use this step-by-step-guide to the Travel referral (Form B) to apply for the Patient

This section needs to be completed by the clinician referring the patient.

This section should include any further details to support the patient’s need for accommodation, including any further accommodation requirements.

Sect

ion

Signature to certify information and acknowledgment of possible sharing of information.

Clinician or representative must sign this form as they are providing medical advice relating to the patient.

Sect

ion

This section needs to be completed by the clinician referring the patient.

Sect

ion

The clinical reason for an escort needs to be completed.

Further details on travel requirements can also be provided in this section such as accessibility requirements, restrictions to travel based on mode or distance, or if the patient requires assistance when travelling.

Sect

ion

To register or update a patient’s personal details please use the Patient registration (Form A). To confirm patient attendance at an appointment please fill out the Appointment attendance (Form C).

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