Synapse Brokerage Program Guidelines

Size: px
Start display at page:

Download "Synapse Brokerage Program Guidelines"

Transcription

1 Synapse Brokerage Program Guidelines Overview: The New South Wales (NSW) Department of Family and Community Services - Ageing, Disability and Home Care (ADHC) has provided funds to Synapse for a Brokerage Program in NSW. As this is a NSW state government funded initiative, Synapse s Brokerage Program is only available to NSW residents. What is the aim of the Brokerage Program? The aim of the Brokerage Program is to support people affected by brain injuries to address, or partially address, an individual goal related to enhancing quality of life, developing skills, and / or building capacity to live more independently. What is a brokerage program package? The maximum Brokerage Program package is $2,500 (plus GST). In exceptional circumstances funds requested may exceed that amount. When are brokerage program packages offered? Synapse s Brokerage Program Panel considers applications every 6 weeks throughout the year. Approximately $25,000 of worth of funding packages will be allocated each quarter. Who can apply for a Brokerage Program Package? If you are a person with a brain injury, you may apply on your own behalf If you are a carer, family member or individual supporting a person with a brain injury, you may also apply on behalf of that person If you are a person with a brain injury, you may ask a service provider to assist you in making the application, or, if you cannot find supports Synapse may be able to assist you. If you are a service provider to a person with a brain injury, then you can apply on behalf of that person Previous applicants who have received funding through the Brokerage Program in the past may apply again for a different purpose. However, if there are more applications than funds available, people who have not received funding before will be given priority. How do I apply for a brokerage program package? Any person requesting funds will need to submit a completed application form. The form can be accessed on the Synapse website or by requesting it from Synapse. Anyone completing the application will need to provide as much detail as possible to enable us to understand the applicant s goal(s), general situation and to demonstrate a clear need. Applications also need to demonstrate that: The person has a brain injury and supporting documentation is provided Funds are not available from other sources to be utilised for the services or equipment (including under the National Disability Insurance Scheme (NDIS)) The services are delivered by a fit and proper organisation or individual (e.g. with Work Health Safety policies and relevant insurance cover); and

2 Any equipment acquired will be covered by a warranty. You are encouraged to contact the Synapse Information and Referral Service to discuss possible avenues of support prior to lodging a brokerage application. Please refer to these Synapse Brokerage Program Guidelines while completing the Application Form. Submit the application by post, or fax, more details on how to lodge your application are at the end of this document. What happens when a brokerage program application is received? Synapse will receive, acknowledge and facilitate the assessment and approval process. Applications that are deemed complete, compliant with these guidelines and contain all necessary information will proceed automatically to the next panel meeting. Applications that are incomplete or have insufficient accompanying information will not be reviewed by the panel. In such instances, the Brokerage Program Coordinator will contact the applicant to seek any missing information. The application can then be considered at the next scheduled panel meeting. Applications will be considered by the Synapse Brokerage Panel that meets every 6 weeks. Panel meeting dates are advertised on the Synapse website, but are subject to change in the event that quorum of panel members cannot attend on the previously set panel meeting date. The panel comprises the Synapse Brokerage Program Coordinator and minimum of 3 other members who have been appointed following a selection process. The appointed members of the panel include people with a lived experience of brain injury, professionals with experience working with people with a brain injury, as well as members of the community. A panel can also be convened to consider any applications needing to be dealt with urgently, however this is only in exceptional circumstances. In the event that funding is not sufficient to meet the requests of all eligible applicants, a decision to partially fund, not to fund, or to defer consideration may be made. Where possible, the Brokerage Panel will suggest alternative services or funding sources when an application is unsuccessful. All applicants will be informed of the panel s decision in relation to their application. What can the funds be used for? The purpose of the application should be for goods or services to assist the person with the impact of a brain injury. Packages are intended to be used for individual personal goals that have clear and specific outcomes. The packages are for short-term or one-off purposes.

3 Examples of allowable uses of Brokerage Program funding; NEUROPSYCHOLOGICAL ASSESSMENT: to fund a Neuropsychological Assessment conducted by a specialist clinical Neuropsychologist. This involves compressive testing of cognitive, psychological, emotional and behavioural functioning. A report is then provided to that details the findings of the assessment. This type of assessment can highlight cognitive strengths and weaknesses for someone affected by brain injury. Neuropsychological Assessment report may assist someone affected by brain injury to demonstrate eligibility for funding under the National Disability Insurance Scheme (NDIS) or Disability Support Pension (DSP). COMMUNITY ACCESS: to purchase disability service provider programs, private companion carers and/or community-based activity program(s) for a fixed, pre-determined period to achieve community re-integration goal(s) when no other funded service is available. ALLIED HEALTH / REHABILITATION SUPPORT: to purchase allied health interventions or therapy programs, for a fixed, pre-determined period to address a specific physical health goal(s) when no other funded service is available. For example: Physical conditioning program including personal trainers and / or gym-based exercise programs; Driver assessment and / or retraining; Home access assessment or equipment review; or Where an up to date assessment is needed e.g. neuropsychological assessment EDUCATION / TRAINING: to purchase training or educational programs, for a fixed, predetermined period to address specific goal(s) related to employment or vocational goal(s) when no other funded service is available. For example; Vocational training program/course Training to enhance employment prospects PURCHASE OF GOODS / EQUIPMENT / HOME MODIFICATIONS: one-off purchase of goods that would assist the person to achieve independent living, communication, and mobility related goal(s). This is confined to goods not available through Enable NSW (Tel: ) or home modification schemes. Please include any necessary assessments and support or training the person may need to use the goods. For example: Assistive Technology - such as communication devices or tablet devices, plus any necessary training to use the device. For people considering whether to apply for a tablet device we recommend reading the following Fact Sheet: Should I get a Tablet Device? PARTICIPATION IN RECREATION / LEISURE / SPORTS ACTIVITIES: to purchase physical, recreational, social, leisure, sports based programs, for a fixed, pre-determined period to address specific goal(s) when no other funded service is available. For example; Personal training program Fitness program Yoga course Leisure program/camp

4 RESPITE: to purchase respite services for a fixed and pre-determined period under the following circumstances: No other funded respite care options are available (e.g. HACC-funded residential, inhome or day centre respite services); Where other respite options are available but they have a waiting list, and waiting would lead to imminent risk for the person with brain injury and / or their carer(s); or The respite required is a short term service to avert crisis and / or to assist in achievement of a person s goals. What the funds cannot be used for? Packages should not be used to establish ongoing supports that will result in distress to people when they cease. Any application seeking funding for ongoing therapies and supports will not be approved. Applications that are requesting supports previously provided under the brokerage program will not be approved other than in exceptional circumstances. The funds cannot be used for services that are available by alternative means. Applicants will need to demonstrate that it has not been possible to obtain the funds requested from any other sources. For advice or assistance in this regard please contact our Information and Referral service. Funds cannot be reimbursed for products or services purchased prior to the application being submitted for review by the Panel. No assumptions should be made regarding the outcome of the Panel s deliberation. Funds cannot be provided to purchase products or services that are purchased from international websites and charged in foreign currency. Funds cannot be provided to purchase goods or services that are unrelated to the applicant s brain injury. Are any particular Brokerage Program applications given priority access to the funds? Yes, those applicants seeking Brokerage Program funding to obtain a Neuropsychological Assessment (where they have not had a Neuropsychological assessment in the past) will be given top priority. Those applicants seeking Brokerage Program funding who have not received funding before will be given next priority. What responsibilities does an applicant have? The applicant will be responsible for: Ensuring the application is developed with individual meaningful goals in mind; Communicating the intention to apply with people likely to be involved in the process such as a guardian, support person or case manager and clarifying who will take responsibility for its administration; Providing enough details including goods or services and their associated costs in the application form to show how the requested amount was calculated and how the funds will be used;

5 Ensuring that the agency or service receiving the funds is able to generate a correctly rendered tax invoice in order for the funds to be managed and expended for the approved purpose; Satisfying Synapse that: Any equipment obtained with the funding will be covered by a warranty; Any modifications proposed will be carried out by a licensed operator; and The provider of any services has the necessary insurances, qualifications to deliver the services and meets Work Health and Safety obligations; Ensuring that the package is administered/spent consistently with the approved application and used solely for the approved purpose; Ensuring the funds are activated within 3 months of being approved and used within 6 months of approval; Informing Synapse if funds are no longer required and promptly returning any funds that cannot be used for the approved purpose; Providing accurate information; and Promptly providing Synapse with a brief report upon expenditure of the funds, detailing how they were spent, and their impact on the person s individual goals. Why was my application not successful? Applications may be unsuccessful if: The applicant does not have a brain injury; The applicant has not provided evidence of having a brain injury; The information provided was insufficient and / or does not provide an adequate explanation or basis for the request; Alternative supports and / or funding sources have not been explored; The requested support is available and accessible in the community; There is no evidence of an individual plan or goals for the person with the brain injury; Other applicants were considered to be a higher priority, and there is insufficient funding to fund all applications; or The needs of the person are significantly more complex than the funding is able to address; The goods or services were purchased prior to the brokerage application being submitted for review by the Panel. What if I have a complaint about the procedure or want to appeal the Brokerage panel s decision? Complaints Procedure: The rights and responsibilities of persons using the services of Synapse can be made can be found on our website at:

6 When an applicant is unhappy with the handling of the application or decision not to fund their application, they are encouraged to ring and discuss the outcome with Synapse. Complaints are managed in accordance with Complaints Resolution Policy that can also be found on our website at: Appeal Procedure: Should an applicant believe that the Brokerage Panel has made a decision that does not make sense or is based on inadequate information the applicant or primary contact may appeal in writing to the CEO of Synapse, explaining their concerns and reason(s) for asking the panel to re-assess the application. Any decision not to approve an application from people previously granted brokerage funds due to a need to prioritise applications from other people with brain injury in NSW will not be subject to appeal.

NDIS Frequently Asked Questions

NDIS Frequently Asked Questions Date: 26/10/2017 Author: NDIS Readiness Team Table of Contents 1 About the NDIS... 1 2 Eligibility... 2 3 NDIS Supports... 3 4 Getting ready to move to the NDIS... 7 5 Getting my plan started... 8 6 What

More information

Lee & Lyons Lawyers 1/131 Macquarie Street SYDNEY NSW AUSTRALIA 2000 Tel: (02)

Lee & Lyons Lawyers 1/131 Macquarie Street SYDNEY NSW AUSTRALIA 2000 Tel: (02) The Impact of the National Disability Insurance Scheme on Catastrophic Injury Cases Presentation to the NSW Claims Discussion Group by Lucinda Lyons, Partner Joseph Callaghan, Senior Associate Lee & Lyons

More information

WorkCover Work Capacity Guidelines

WorkCover Work Capacity Guidelines 4228 SPECIAL SUPPLEMENT 28 September 2012 WorkCover Work Capacity Guidelines Workers Compensation Act 1987 Workplace Injury Management and Workers Compensation Act 1998 I, Julie Newman, the Acting Chief

More information

WORKCOVER NSW SNA TRAINING

WORKCOVER NSW SNA TRAINING Frequently Asked Questions About the SNA process How will SNA assessors be introduced and described to clients? SNA assessors will be introduced to clients by the referring insurer. A key message to clients

More information

The rollout of the National Disability Insurance Scheme in NSW Provider information sessions May - June 2016

The rollout of the National Disability Insurance Scheme in NSW Provider information sessions May - June 2016 The rollout of the National Disability Insurance Scheme in NSW Provider information sessions May - June 2016 This session will cover the following topics Transferring services to the NGO sector How the

More information

NCAA CATASTROPHIC INJURY INSURANCE PROGRAM FREQUENTLY ASKED QUESTIONS

NCAA CATASTROPHIC INJURY INSURANCE PROGRAM FREQUENTLY ASKED QUESTIONS NCAA CATASTROPHIC INJURY INSURANCE PROGRAM FREQUENTLY ASKED QUESTIONS APPLICABLE TO 8/1/17 TO 7/31/2020 POLICY PERIOD This document is a summary of the NCAA Catastrophic Injury Insurance Program. The insurance

More information

Service Agreement. Agreement for the Provision of Services

Service Agreement. Agreement for the Provision of Services Service Agreement A Service Agreement is made between a person and Cara or a person s representative and Cara. A person s representative is someone close to the person, for example, a family member or

More information

Canada Pension Plan: Disability Benefits

Canada Pension Plan: Disability Benefits WELLSPRING CANCER SUPPORT FOUNDATION A Lifeline to Cancer Support Canada Pension Plan: Resource Sheet The Money Matters program in Calgary, Alberta is generously supported by The Calgary Foundation and

More information

Key Features of the Assisted Living Insurance

Key Features of the Assisted Living Insurance Key Features of the Assisted Living Insurance Introduction The Financial Conduct Authority is a financial services regulator. It requires us, National Friendly, to give you this important information to

More information

3.14. Supportive Services for People with Disabilities. Chapter 3 Section. Background. Ministry of Community and Social Services

3.14. Supportive Services for People with Disabilities. Chapter 3 Section. Background. Ministry of Community and Social Services Chapter 3 Section 3.14 Ministry of Community and Social Services Supportive Services for People with Disabilities Background Figure 1: Supportive Services Expenditures, 2010/11 Source of data: Ministry

More information

Still Waters Counseling, Consulting, and Psychological Services Initial Contact Information Sheet Testing

Still Waters Counseling, Consulting, and Psychological Services Initial Contact Information Sheet Testing Initial Contact Information Sheet Testing Name: DOB: Date of Contact: Home Address: Phone numbers / Leave message? : Method for Reminder Messages: Phone: E-mail: Emergency Contact: Name of person Phone

More information

Long-term care Insurance

Long-term care Insurance More and more Americans are aware of the steadily growing costs of long-term care. A lifetime of retirement savings can be wiped out by an unexpected need for nursing home, assisted living, or at-home

More information

Device Protect insurance

Device Protect insurance Device Protect insurance 1 Peace of mind for your new mobile or tablet Life is good with a new mobile phone or tablet. Device Protect gives you peace of mind by getting you back on track with a replacement

More information

SAMPLE. Gold Disability Income Cover Policy

SAMPLE. Gold Disability Income Cover Policy Gold Disability Income Cover Policy This is your Gold Disability Income Cover Policy. It is an important document and should be kept in a safe place. Please take the time to read this document. Effective

More information

February 1, Basic Long Term Disability MMC

February 1, Basic Long Term Disability MMC February 1, 2008 MMC This plan provides you with income in case you can t work for an extended period of time because of an injury or illness. Effective January 1, 2007, benefits under MMC s Basic and

More information

Important things you need to know. Device Protect Combined Product Disclosure Statement, Policy Terms and Conditions and Financial Services Guide

Important things you need to know. Device Protect Combined Product Disclosure Statement, Policy Terms and Conditions and Financial Services Guide Important things you need to know Device Protect Combined Product Disclosure Statement, Policy Terms and Conditions and Financial Services Guide 1 Combined product disclosure statement, policy terms and

More information

Re: TUNSW Submission on Protections for Residents of Long Term Supported Group Accommodation in NSW

Re: TUNSW Submission on Protections for Residents of Long Term Supported Group Accommodation in NSW 11 March 2018 Attn: Resident Rights Consultation Process Family and Community Services Level 13, 4-6 Bligh Street Sydney NSW 2000 To whom it may concern, Re: TUNSW Submission on Protections for Residents

More information

Worker s injury claim form

Worker s injury claim form Worker s injury claim form Workers Compensation Act 1987 Workplace Injury Management and Workers Compensation Act 1998 Use this form to make a workers compensation claim for weekly payments or medical,

More information

INJURY MANAGEMENT PROGRAM

INJURY MANAGEMENT PROGRAM Well@Work INJURY MANAGEMENT PROGRAM HRD-WHS-PRO-040.9 Injury Management Program 2017 June Page 1 of 27 Contents 1 2 3 4 5 6 Introduction... 4 Principles... 4 Definitions... 4 3.1 Injury Management... 4

More information

APPLICATION FOR DISTRIBUTION

APPLICATION FOR DISTRIBUTION APPLICATION FOR DISTRIBUTION GENERAL INFORMATION Background Application Eligibility The Brain and Spinal Injury Trust Fund ( Trust Fund ) was established by law to collect additional DUI fines and fees

More information

WORKCOVER GUIDELINES ON INDEPENDENT MEDICAL EXAMINATIONS AND REPORTS

WORKCOVER GUIDELINES ON INDEPENDENT MEDICAL EXAMINATIONS AND REPORTS 1756 OFFICIAL NOTICES 17 April 2009 WORKCOVER GUIDELINES ON INDEPENDENT MEDICAL EXAMINATIONS AND REPORTS I, John Watson, Acting Chief Executive Officer of the WorkCover Authority of New South Wales, under

More information

PAYROLL DECLARATION FOR WORKERS COMPENSATION INSURANCE

PAYROLL DECLARATION FOR WORKERS COMPENSATION INSURANCE Instructions for filling in a PAYROLL DECLARATION FOR WORKERS COMPENSATION INSURANCE 1.1.2016 It is important that you complete all information carefully, since it will be used to calculate the premiums

More information

World Bank Group Directive

World Bank Group Directive World Bank Group Directive Staff Rule 6.11 - Workers' Compensation Program Bank Access to Information Policy Designation Public Catalogue Number HRD3.03-DIR.114 Issued March 13, 2017 Effective October

More information

Thank you for the opportunity to comment on the Review of the Solar Bonus Scheme.

Thank you for the opportunity to comment on the Review of the Solar Bonus Scheme. 29 September 2010 Solar Bonus Review Industry & Investment NSW Level 17, 227 Elizabeth Street Sydney, NSW 2000 Solarbonus.review@industry.nsw.gov.au Thank you for the opportunity to comment on the Review

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM V-INSURANCE GROUP Corporate Authorised Representative of Willis Office use only Policy Number: 01PO527349 Claim Number: PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR LITTLE ATHLETICS AUSTRALIA V-Insurance

More information

79 Anson Road #11-05 Singapore Tel: Fax: Web:

79 Anson Road #11-05 Singapore Tel: Fax: Web: 79 Anson Road #11-05 Singapore 079906 Tel: 6438 8900 Fax: 6438 6989 Email: lia@lia.org.sg Web: www.lia.org.sg Life Insurance Association, 4th Edition, January 2013 LIA Code of Life Insurance Practice This

More information

P.L. 2005, CHAPTER 172, approved August 5, 2005 Assembly, No (First Reprint)

P.L. 2005, CHAPTER 172, approved August 5, 2005 Assembly, No (First Reprint) P.L. 00, CHAPTER, approved August, 00 Assembly, No. (First Reprint) - C.:S-. - Note to - 0 0 0 AN ACT concerning managed behavioral health care services and amending and supplementing P.L., c.. BE IT ENACTED

More information

Financial Services and Credit Guide

Financial Services and Credit Guide Green Capital Financial Services and Credit Guide Why this Guide is important to you This Guide explains the financial planning and credit services we provide, as well as giving you important information

More information

Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA Phone Fax:

Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA Phone Fax: Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA 98005 Phone 425-301-9869 Fax: 866-546-1618 Welcome to my practice. I look forward to meeting with

More information

FITNESS PROFESSIONALS LTD INSURANCE SCHEME

FITNESS PROFESSIONALS LTD INSURANCE SCHEME FITNESS PROFESSIONALS LTD INSURANCE SCHEME Fitness Professionals Ltd (FitPro) is conscious that fitness professionals in today s industry have an increasing risk of a claim being made against them. This

More information

Directive. Staff Rule 6.11, Workers' Compensation. Bank Access to Information Policy Designation Public. Catalogue Number. Issued

Directive. Staff Rule 6.11, Workers' Compensation. Bank Access to Information Policy Designation Public. Catalogue Number. Issued Directive Staff Rule 6.11, Workers' Compensation Bank Access to Information Policy Designation Public Catalogue Number Issued Effective October 1, 2011 Retired March 12, 2017 Content Applicable to Issuer

More information

Financial Services Guide

Financial Services Guide Financial Services Guide Why this Guide is important to you This Guide explains the financial planning services we provide, as well as giving you important information that will help you decide if you

More information

Long Term Care Insurance (LTCi)

Long Term Care Insurance (LTCi) Frequently Asked Questions about Long Term Care Insurance (LTCi) November 2017 Eric Burkard, CLTC What is Long Term Care? Long-term care is defined as needing assistance for more than 90 days with your

More information

FINANCIAL PLANNING FINANCIAL SERVICES GUIDE (Part 1) Date of issue 1 November Version 11.0

FINANCIAL PLANNING FINANCIAL SERVICES GUIDE (Part 1) Date of issue 1 November Version 11.0 FINANCIAL PLANNING FINANCIAL SERVICES GUIDE (Part 1) Date of issue 1 November 2018 - Version 11.0 InterPrac Financial Planning Pty Ltd ABN 14 076 093 680 Australian Financial Services Licence Number: 246638

More information

FINANCIAL PLANNING FINANCIAL SERVICES GUIDE (Part 1) Date of issue 1 November Version 11.0

FINANCIAL PLANNING FINANCIAL SERVICES GUIDE (Part 1) Date of issue 1 November Version 11.0 FINANCIAL PLANNING FINANCIAL SERVICES GUIDE (Part 1) Date of issue 1 November 2018 - Version 11.0 InterPrac Financial Planning Pty Ltd ABN 14 076 093 680 Australian Financial Services Licence Number: 246638

More information

YMCA SOUTH AUSTRALIA Privacy Policy

YMCA SOUTH AUSTRALIA Privacy Policy Policy Title: Author: YMCA SOUTH AUSTRALIA Created by: 1 P a g e Policy Title: Author: 1. Introduction considers the privacy of individuals, staff, volunteers, clients, Member Associations and associated

More information

MORTGAGE AND INCOME PROTECTION

MORTGAGE AND INCOME PROTECTION CUSTOMER GUIDE MORTGAGE AND INCOME PROTECTION Are you protecting your mortgage and rent payments? If you couldn t work for months or even years because of illness or injury, would you be able to cover

More information

IMPLEMENTING LEGISLATIVE REFORM: THE SOUTH AUSTRALIAN STORY

IMPLEMENTING LEGISLATIVE REFORM: THE SOUTH AUSTRALIAN STORY IMPLEMENTING LEGISLATIVE REFORM: THE SOUTH AUSTRALIAN STORY Prepared by Wayne Potter, Ian Rhodes and Emma Siami Presented to the Institute of Actuaries of Australia 12 th Accident Compensation Seminar

More information

LIA. Life Insurance Practice. Code of LIA CODE OF LIFE INSURANCE PRACTICE

LIA. Life Insurance Practice. Code of LIA CODE OF LIFE INSURANCE PRACTICE LIFE IS WORTH PROTECTING. INVEST IN IT. LIA Code of Life Insurance Practice LIA CODE OF LIFE INSURANCE PRACTICE The information in this LIA Code is of general nature, and does not give any life insurance

More information

EZYPAY CUSTOMER TERMS AND CONDITIONS. Ezypay s fee in the event that I fail to meet a periodic direct debit; and

EZYPAY CUSTOMER TERMS AND CONDITIONS. Ezypay s fee in the event that I fail to meet a periodic direct debit; and EZYPAY CUSTOMER TERMS AND CONDITIONS My authority to Ezypay to direct debit my account 1. I authorise Ezypay to: make periodic direct debits of my account for the Principal s fees; make periodic direct

More information

Device Protect insurance

Device Protect insurance Device Protect insurance 1 Peace of mind for your new mobile or tablet Policy summary (Please see policy terms for full details) Your premium and what it covers Life is good with a new mobile phone or

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Willis Australia Limited ABN 90 000 321 237 AFS 240600 Office use only Policy Number: SUA/003700 Claim Number:. PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR NETBALL QUEENSLAND Willis Australia Limited

More information

Mine Wealth + Wellbeing Super Injury and Sickness Claim Form

Mine Wealth + Wellbeing Super Injury and Sickness Claim Form Mine Wealth + Wellbeing Super Injury and Sickness Claim Form This claim form consists of 3 parts and all sections must be completed in full. Section A Claimant Statement Section B Doctor Statement Section

More information

CLUB SUPER PERSONAL ACCIDENT AND SICKNESS CLAIM FORM

CLUB SUPER PERSONAL ACCIDENT AND SICKNESS CLAIM FORM 1 of 7 CLUB SUPER PERSONAL ACCIDENT AND SICKNESS CLAIM FORM This claim form consists of 3 parts and all sections must be completed in full. Section A Claimant Statement The claimant is to complete all

More information

TOTALCAREMAX PERSONAL

TOTALCAREMAX PERSONAL TOTALCAREMAX PERSONAL OPTIONAL BENEFIT APPENDIX Mortgage and Income Protection Benefit This appendix only applies if cover under the policy schedule includes the Mortgage and Income Protection Benefit.

More information

Dear Applicant, If you have any questions, please Sincerely, Brain Injury Community Support Program Review Committee

Dear Applicant, If you have any questions, please Sincerely, Brain Injury Community Support Program Review Committee Dear Applicant, 52 Pleasant Street Concord, NH 03301 Help line: (800) 773-8400 Tel: (603) 225-8400 Fax: (603) 228-6749 www.bianh.org THE VOICE OF BRAIN INJURY Thank you for your interest in the. This program

More information

PIP Claim Information Standard Policy

PIP Claim Information Standard Policy PIP Claim Information Standard Policy We understand this may be a difficult and confusing experience and we wish to assist you in any way we can. We hope the following information will help explain the

More information

Application for Reinstatement

Application for Reinstatement Application for Reinstatement Completion instructions For owners of adult plans: Read section 3, then Complete sections 1, 2 and 7. Mark boxes with ( ) where appropriate, otherwise use block letters. Leave

More information

MED-EL CORPORATION NOTICE OF PRIVACY PRACTICES

MED-EL CORPORATION NOTICE OF PRIVACY PRACTICES MED-EL CORPORATION NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY

More information

Budget 2017: What it means for carers

Budget 2017: What it means for carers Budget 2017: What it means for carers Set out below is an overview of the key 2017-18 federal Budget measures that may affect carers. There may be other relevant measures that are not included in this

More information

NDIS & NIIS An Introduction. Julie Evans Institute of Actuaries of Australia

NDIS & NIIS An Introduction. Julie Evans Institute of Actuaries of Australia NDIS & NIIS An Introduction Julie Evans Institute of Actuaries of Australia Productivity Commission Inquiry late 2009 Inquiry announced Apr 2010 Inquiry commenced May 2010 Issues Paper 2010/2011 Submissions

More information

16-18 Bursary Guidance Notes 2018/19

16-18 Bursary Guidance Notes 2018/19 16-18 Bursary Guidance Notes 2018/19 This application is for Access Creative College students who are aged 16-18 on 31 st August 2018 and need financial help so that they can participate in learning. All

More information

FINANCIAL PLANNING FINANCIAL SERVICES GUIDE Part 1

FINANCIAL PLANNING FINANCIAL SERVICES GUIDE Part 1 FINANCIAL PLANNING FINANCIAL SERVICES GUIDE Part 1 Date of issue 30 May 2014 (v8.0) Authorised Representative of InterPrac Financial Planning Pty Ltd ABN 14 076 093 680 Australian Financial Services Licence

More information

Engineering Consultant Scheme Questions December 2014

Engineering Consultant Scheme Questions December 2014 Engineering Consultant Scheme Questions December 2014 BUYER QUESTIONS 1. Are there thresholds for obtaining a certain number of quotes when buying off the Scheme? The Engineering Consultant Scheme (ECS

More information

GPASO BENEFITS Frequently Asked Questions & Answers - April 2014

GPASO BENEFITS Frequently Asked Questions & Answers - April 2014 GPASO BENEFITS Frequently Asked Questions & Answers - April 2014 Eligibility Who is eligible for this benefit? The GPASO health scheme is open to government employees who are about to retire and will receive

More information

PLAN of Massachusetts & Rhode Island, Inc. Special Needs Pooled Trust: Disbursement Guidelines

PLAN of Massachusetts & Rhode Island, Inc. Special Needs Pooled Trust: Disbursement Guidelines PLAN of Massachusetts & Rhode Island, Inc. Special Needs Pooled Trust: Disbursement Guidelines January, 2018 Page 1 of 12 DISBURSEMENT OF FUNDS FROM SPECIAL NEEDS POOLED TRUST ACCOUNTS GUIDING PRINCIPLES

More information

Group Income Protection. Helping staff get better and back to work quicker. Retirement Investments Insurance Health

Group Income Protection. Helping staff get better and back to work quicker. Retirement Investments Insurance Health For financial adviser use only. Not approved for use with customers. Group Income Protection Helping staff get better and back to work quicker Retirement Investments Insurance Health Contents 3 Protecting

More information

FSPLPI02 - SQA Unit Code H5GB 04 Underwrite straightforward alterations to life, pensions and investment contracts

FSPLPI02 - SQA Unit Code H5GB 04 Underwrite straightforward alterations to life, pensions and investment contracts Underwrite straightforward alterations to life, pensions and investment Overview This unit may be suitable for you if you work for, or on behalf of, an insurer or other product provider. Your work must

More information

Attached to and forming part of Group Policy No issued to UNIVERSITY OF WATERLOO

Attached to and forming part of Group Policy No issued to UNIVERSITY OF WATERLOO ATTENTION: The Great-West Life Assurance Company. This PDF version of the policy, together with any amendments that may not be included with this PDF, constitutes the official version of the policy. This

More information

Injury and Sickness - Claim Form

Injury and Sickness - Claim Form Injury and Sickness - Claim Form This claim form consists of 3 parts and must be completed in full. Your claim cannot be assessed until all sections are completed the original form is submitted. To have

More information

HOLIDAY PROGRAM ENROLMENT FORM

HOLIDAY PROGRAM ENROLMENT FORM MQ Sport and the Macquarie University Sports & Aquatic Centre are trading names of U@MQ ABN 27 125 926 169, a controlled entity of Macquarie University Macquarie University NSW 2109 Australia T: +61 (2)

More information

Revised Draft Ballot Paper

Revised Draft Ballot Paper Revised Draft Ballot Paper Introduction Over the course of the last two weekends, the Members of the Assembly have considered a range of issues in relation to the Challenges and Opportunities of an Ageing

More information

FINANCIAL SERVICES COUNCIL CLAIMS GUIDELINES

FINANCIAL SERVICES COUNCIL CLAIMS GUIDELINES FINANCIAL SERVICES COUNCIL CLAIMS GUIDELINES CLAIMS GUIDELINES FOR MENTAL HEALTH CONDITIONS FSC Guidance Note No. 14 September 2003 TABLE OF CONTENTS Paragraph Page Introduction 1 2 Insurer Basics 2 2

More information

AGREEMENT AND INFORMED CONSENT FOR TREATMENT

AGREEMENT AND INFORMED CONSENT FOR TREATMENT Joseph M. Cereghino, Psy.D. Licensed Psychologist Family Institute, P.C. 4110 Pacific Ave., Suite 102, Forest Grove, OR 97116 Tigard Office: 9600 SW Oak St., Suite 280, Tigard, OR 97223 (503) 601-5400

More information

Sports Injury Claim Form

Sports Injury Claim Form Sports Underwriting Australia Sports Underwriting Australia Claims Department PO E: austclaims@aig.com Box 2717, Taren Point. NSW, 2229 Ph: 1800 812 363 Tel: 1300 363 413 Fax: +61 2 9524 9003 Post: AIG

More information

Amergin THE NDIS PROVIDER GUIDE. Find out what you need to do to become a registered NDIS provider.

Amergin THE NDIS PROVIDER GUIDE. Find out what you need to do to become a registered NDIS provider. Amergin THE NDIS PROVIDER GUIDE Find out what you need to do to become a registered NDIS provider. Becoming a Registered NDIS Provider The National Disability Insurance Scheme (NDIS) presents some big

More information

Payments towards non residential social care services

Payments towards non residential social care services Payments towards non residential social care services Information about the Adults & Health Charging Policy and how it affects you. 1st April 2017 to 31st March 2018 Chargeable services This booklet explains

More information

Report by the Local Government and Social Care Ombudsman

Report by the Local Government and Social Care Ombudsman Report by the Local Government and Social Care Ombudsman Investigation into a complaint against South Tyneside Metropolitan Borough Council (reference number: 16 005 776) 13 February 2018 Local Government

More information

Copyright License and First Aid Services. Agreement to act as a course training Co provider on an Independent Business basis

Copyright License and First Aid Services. Agreement to act as a course training Co provider on an Independent Business basis Copyright License and First Aid Services Agreement to act as a course training Co provider on an Independent Business basis Introduction This agreement is made on. and is between National First Aid National

More information

Combined Insurance Claim Form

Combined Insurance Claim Form Combined Insurance Claim Form Important Instructions on How to Complete the Attached Claim Form and How We Assess Claims Please read these important instructions on how to complete the attached Claim Form.

More information

Event contact dates Date Time Promotional Period 1 25 March 2017 Promotion Opens: Fri 10/03/17 12:00am

Event contact dates Date Time Promotional Period 1 25 March 2017 Promotion Opens: Fri 10/03/17 12:00am TERMS AND CONDITIONS OF ENTRY INTO 2017 Citi Lounge promotion by Citi 1. The Promoter is Citigroup Pty Limited ABN 88 004 325 080 of 2 Park Street, Sydney NSW 2000 ("Citibank" or "the Promoter") tel: 13

More information

*ID: If Domestic Partner coverage is offered, it can only be offered to opposite sex partner Nursing Home Care

*ID: If Domestic Partner coverage is offered, it can only be offered to opposite sex partner Nursing Home Care PLAN DETAILS Prudential Long Term Care SM Insurance Standard Provisions and Plan Features for the Church Pension Fund ISSUED BY THE PRUDENTIAL INSURANCE COMPANY OF AMERICA Eligibility to Active and Retired

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy Number: Claim Number:. PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR NETBALL WA V-Insurance Group Pty Ltd Authorised Representative No. 432898 an authorised representative of Willis

More information

FINANCIAL PLANNING FINANCIAL SERVICES GUIDE Part 1

FINANCIAL PLANNING FINANCIAL SERVICES GUIDE Part 1 FINANCIAL PLANNING FINANCIAL SERVICES GUIDE Part 1 Date of issue 30 June 2018 (v10.0) InterPrac Financial Planning Pty Ltd ABN 14 076 093 680 Australian Financial Services Licence Number: 246638 Level

More information

ELECTRONIC FUNDS TRANSFER FORM (EFT) for Claim Payments

ELECTRONIC FUNDS TRANSFER FORM (EFT) for Claim Payments Claim Form This is the form to use when making a claim on any policy provided by AFA Pty Ltd, AFS Licence No 247122. Correct completion of these forms will assist us to make accurate and faster decisions

More information

A Layman's Guide To ICBC Part 7 Benefits

A Layman's Guide To ICBC Part 7 Benefits A Layman's Guide To ICBC Part 7 Benefits Prepared for MADD Revised March 2018 This guide was initially prepared in February, 2005 at the request of MADD to provide a layman's guide to ICBC no-fault/part

More information

Important Instructions on How to Complete the Attached Claim Form and How We Assess Claims

Important Instructions on How to Complete the Attached Claim Form and How We Assess Claims A division of Chubb Insurance Australia Limited Combined Insurance Claim Form Important Instructions on How to Complete the Attached Claim Form and How We Assess Claims Please read these important instructions

More information

Financial Services Guide

Financial Services Guide The Advantage Group Financial Planning Pty Ltd Financial Services Guide Why this Guide is important to you This Guide explains the financial planning services we provide, as well as giving you important

More information

Chapter 8 Disability 8.1

Chapter 8 Disability 8.1 Chapter 8 Fast Facts STD benefits (if elected) generally continue 60% of your pre-disability pay for up to 11 weeks if you become disabled and unable to work. Once an eligible employee has been disabled

More information

GAHANNA COUNSELING, LLC

GAHANNA COUNSELING, LLC Client Information and Acknowledgment of Informed Consent to Treatment GAHANNA COUNSELING, LLC 540 Officenter Pl., Ste. 290, Gahanna, OH 43230 - Ph: 1-888-336-1772 I am independently licensed as a LPCC

More information

Benefits Handbook Date January 1, Optional Long Term Disability Marsh & McLennan Companies

Benefits Handbook Date January 1, Optional Long Term Disability Marsh & McLennan Companies Date January 1, 2016 Marsh & McLennan Companies SPD and Plan Document This section provides a summary of the Optional Long Term Disability Plan (the Plan ) as of January 1, 2015. This section, together

More information

INTO Uniplan. The complete insurance service for international students

INTO Uniplan. The complete insurance service for international students INTO Uniplan The complete insurance service for international students INTO Uniplan Insurance for international students It is essential that you take out adequate insurance when you travel to the UK to

More information

Equine Claim Form. Important Notes. Supporting Documentation

Equine Claim Form. Important Notes. Supporting Documentation Equine Claim Form This form can be used to submit a claim under the following benefits: Veterinary Fees Death Permanent Loss of Use If you are submitting a new claim: Complete sections 1-5 and pass the

More information

Department of Infrastructure. Housing (Public Sector Sheltered Housing) (Criteria for Allocation of Housing to Older Persons) Policy 2016

Department of Infrastructure. Housing (Public Sector Sheltered Housing) (Criteria for Allocation of Housing to Older Persons) Policy 2016 SD 2016/0101 c Department of Infrastructure Housing (Miscellaneous Provisions) Act 1976 Housing (Public Sector Sheltered Housing) (Criteria for Allocation of Housing to Older Persons) Policy 2016 Approved

More information

FINANCIAL PLANNING FINANCIAL SERVICES GUIDE Part 1

FINANCIAL PLANNING FINANCIAL SERVICES GUIDE Part 1 FINANCIAL PLANNING FINANCIAL SERVICES GUIDE Part 1 Date of issue 30 June 2018 (v10.0) InterPrac Financial Planning Pty Ltd ABN 14 076 093 680 Australian Financial Services Licence Number: 246638 Level

More information

Please print and complete all the enclosed forms and bring them to your first appointment.

Please print and complete all the enclosed forms and bring them to your first appointment. Dear Valued Patient, Thank you for requesting an appointment in our office. Please print and complete all the enclosed forms and bring them to your first appointment. When you arrive at our office for

More information

Any incomplete or non-completed forms may delay processing of your claim. Please ensure that you have completed/attached the following:

Any incomplete or non-completed forms may delay processing of your claim. Please ensure that you have completed/attached the following: Speedway Australia Personal injury claim form QBE Insurance (Australia) Limited ABN 78 003 191 035 AFSL 239 545 Please Remember Any incomplete or non-completed forms may delay processing of your claim.

More information

Effective Date 7 06 Feb 2018 Incorporating EPA assessment activity Due to IMI expanding its services

Effective Date 7 06 Feb 2018 Incorporating EPA assessment activity Due to IMI expanding its services APPEALS POLICY Issue Number Effective Date Amendments Reason for Amendments 7 06 Feb 2018 Incorporating EPA assessment activity Due to IMI expanding its services INTRODUCTION This document sets out our

More information

Frequently Asked Questions about: Long-stay Contributions (Residential Support Services Maintenance and Accommodation Contributions)

Frequently Asked Questions about: Long-stay Contributions (Residential Support Services Maintenance and Accommodation Contributions) Frequently Asked Questions about: Long-stay Contributions (Residential Support Services Maintenance and Accommodation Contributions) This guide is for information only. It is not a legal interpretation.

More information

Castleford Academy. Educational Visits and School Trips Policy. Governing Body Approval: Revision Date: Version: 1.

Castleford Academy. Educational Visits and School Trips Policy. Governing Body Approval: Revision Date: Version: 1. Castleford Academy Educational Visits and School Trips Policy Governing Body Approval: 19.07.2017 Revision Date: 19.07.2020 Version: 1.0 Contents: Statement of intent 1. Definitions 2. Key roles and responsibilities

More information

FINANCIAL PLANNING FINANCIAL SERVICES GUIDE (Part 1) Date of issue 1 November Version 11.0

FINANCIAL PLANNING FINANCIAL SERVICES GUIDE (Part 1) Date of issue 1 November Version 11.0 FINANCIAL PLANNING FINANCIAL SERVICES GUIDE (Part 1) Date of issue 1 November 2018 - Version 11.0 InterPrac Financial Planning Pty Ltd ABN 14 076 093 680 Australian Financial Services Licence Number: 246638

More information

Changes to your terms and conditions

Changes to your terms and conditions Changes to your terms and conditions As explained earlier, the Insurer is making changes to some of the terms and conditions of your insurance. The key changes, and what they will mean for you, are outlined

More information

EMPLOYEE WORKERS COMPENSATION HANDBOOK 2018

EMPLOYEE WORKERS COMPENSATION HANDBOOK 2018 EMPLOYEE WORKERS COMPENSATION HANDBOOK 2018 The City of Stockton is self-insured for Workers' Compensation benefits. The City pays benefits directly to injured employees, rather than purchasing an insurance

More information

Advice Paper: Individual Financial Assistance (Scheme 6) and Means Testing

Advice Paper: Individual Financial Assistance (Scheme 6) and Means Testing Advice Paper: Individual Financial Assistance (Scheme 6) and Means Testing 21 February 2014 1 Contents Summary 3 Recommendations 3 Introduction 5 Background 6 VSS Interim Findings - Review of Scheme 6:

More information

PARTICIPANT APPLICATION FORM (for participants under 18 years of age)

PARTICIPANT APPLICATION FORM (for participants under 18 years of age) SECTION 1 PARTICIPANT APPLICATION FORM (for participants under 18 years of age) Name:..... [Given Name(s)] [Family Name] Home Address..... City/Suburb.. State/Territory.. Postcode:.... Gender: Male Female

More information

The Summary of Benefits is intended to be a qualified Long Term Care Insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986.

The Summary of Benefits is intended to be a qualified Long Term Care Insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986. First Unum Life Insurance Company 666 Third Avenue New York, New York 10017 1-800-356-5817 LONG TERM CARE INSURANCE OUTLINE OF COVERAGE FOR THE EMPLOYEES OF BLUMENCRANZ KLEPPER WILKINS AND DUBOFSKY LTD.

More information

AUSTRALIAN CANOEING NATIONAL INSURANCE PROGRAM

AUSTRALIAN CANOEING NATIONAL INSURANCE PROGRAM Office use only Policy Number: Claim Number:. AUSTRALIAN CANOEING NATIONAL INSURANCE PROGRAM PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR AUSTRALIAN CANOEING; V-Insurance Group Pty Ltd Authorised Representative

More information

SUMMARY OF MARYLAND STATE EMPLOYEES & RETIREES BEHAVIORAL HEALTH PLAN

SUMMARY OF MARYLAND STATE EMPLOYEES & RETIREES BEHAVIORAL HEALTH PLAN SUMMARY OF MARYLAND STATE EMPLOYEES & RETIREES BEHAVIORAL HEALTH PLAN 2012-2013 Call APS Healthcare Toll-Free: 1-877-239-1458 Website: www.apshelplink.com Company Code: SOM2002 1 of 8 Year 2012-2013 Summary

More information

Arcare Aged Care APP Privacy Policy

Arcare Aged Care APP Privacy Policy Arcare Aged Care APP Privacy Policy Introduction The purpose of this privacy policy is to outline the practices adopted by Arcare Aged Care (Arcare) for the management of personal and health information.

More information

Amendment to Membership Agreement, Disclosure Form, and Evidence of Coverage

Amendment to Membership Agreement, Disclosure Form, and Evidence of Coverage Kaiser Foundation Health Plan, Inc. (Health Plan) is amending your 2016 Individual Plan Membership Agreement, Disclosure Form, ( DF/EOC ) effective January 1, 2017 by sending the Subscriber this Amendment

More information