voss prescriber application form by HC120614114511

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									Vehicle Options Subsidy Scheme (VOSS)

Prescriber Registration Form
VOSS welcomes your professionalism as you join our Registered VOSS Prescriber network.
VOSS aims to offer individualised support for people with a disability who want or need to use their
own vehicle in their everyday lives to improve their social, cultural and economic participation in
their communities.

To become a member of the Registered VOSS Prescriber or RVP network, there are four simple
steps.

Step 1          Complete this Prescriber Registration Form.
                Please read below for details.
Step 2          Participate in VOSS information sessions.
                These sessions will introduce you to VOSS (1 hour) and step you through the
                process for prescription that enables your clients access to the subsidy funding
                (1 day).
Step 3          Continue participation in driver and passenger transport related continuing
                education events.
                These continuing education events are the usual ones that you would be involved in
                for registration with your respective professional organisations.
Step 4          Support the consumer feedback and research activities of VOSS.
                VOSS aims to collect data on met and unmet client need. VOSS hopes to evaluate
                the delivery of VOSS for future improvements to be made. These will be discussed
                at the VOSS training days.

Step 1 Completing this Prescriber Registration Form

By completing the following details you enable VOSS to:

        develop a register of the prescriber workforce for dissemination of
         VOSS information
        develop a list of RVP’s to be available for referral
        allow payments for service to occur (if applicable)

This form has 3 parts. Private providers must complete all 3 parts for payment. All other
prescribers we ask to complete the first 2 parts.




                           Vehicle Options Subsidy Scheme – Prescriber Registration Form Page 1
1.1 Prescriber Register – Confidential Information

The following information will be collected by VOSS as a register of the qualifications, experience
and currency of practice of the prescriber workforce.

Please register your professional qualifications.

Full Name as Registered in your profession

Registration Body

Registration Number

Professional Qualification/s, Institution and
year obtained
Specialist Qualification/s, institution and
year obtained
Driver Trainer Number

Please describe your recency of practice for the past 12 months.


What type of passenger focussed
assessment and intervention have you
been involved with in the last 12 months?
How many clients have you provided this
service to?


What type of driver focussed assessment
and intervention have you been involved
with in the last 12 months?
How many clients have you provided this
service to?


What VOSS relevant professional and
special interest memberships and/or
representations have you been involved
with in the last 12 months?


What continuing education activities related
to vehicle and transport options for people
with disabilities have you participated in
in the last 12 months?




                         Vehicle Options Subsidy Scheme – Prescriber Registration Form Page 2
1.2 List of RVP’s for referral – Public Information

Please write your preferences below for information that will be put on a referral list for DCCS staff
to access electronically and provided to the public at point of referral. By providing this information
here you give consent to this referral information being available within DCCS and for being
provided to the general public.


Contact Person

Business or Employer Name
                                                             Children <6 years
                                                             Children >6 years – 18 years
                                                             Young adults
                                                             Older adults
RVP Experience and
                                                             Passenger needs
Preference for Referral
                                                             Driver needs
                                                             Behavioural needs
(Tick as many relevant
                                                             Physical needs
or add more if needed)
                                                             Cognitive needs
                                                             Complex health needs
                                                             Other (please describe)

RVP Additional Qualifications
                                                             Driver Trained
(Tick if applicable)
Preferred contact time and method
Phone
Mobile Phone
Street Address
Suburb/Town
Postcode
Physical Accessibility
Other Relevant Considerations



1.3 Payment for Service – Confidential Information (Private Providers only)
Banking Institution:

Branch where account held:

BSB Number:

Account number:

Account Name:




                          Vehicle Options Subsidy Scheme – Prescriber Registration Form Page 3
Declaration

Please read and complete the following declaration to VOSS as a part of Disability and Community
Care Services (DCCS).


I declare that:


       The information contained in this form is true and accurate.
       I will inform VOSS of any change to the above information within 2 weeks of these details
        having changed.
       I understand that submitting this VOSS registration form in no way guarantees access to
        funding.
       I understand that part of the above information will be given to the public and available
        electronically for the purpose of referral to my service.
       I understand that DCCS reserves the right to clarify and confirm information provided in this
        VOSS registration form.
       I understand that DCCS reserves the right at any time to exclude any registration or
        application that does not meet the intent of VOSS.
       I agree to participate in one or more VOSS information sessions to learn how to apply the
        VOSS guidelines.
       I agree to read the VOSS guidelines document.


I understand and agree to the declaration above by signing below.
Signature                                                   Date




Printed Full Name




                        Vehicle Options Subsidy Scheme – Prescriber Registration Form Page 4

								
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