Life support concession application form

Life Support Concession/Notification of installation of life support machine Does a member of your household use a life support machine? All households with life support users should complete this form to ensure their electricity retailer and/or water authority are awareof the presence of a Life Support machine at their residential address.
If the electricity and/or water account holder holds an eligible concession card, they can also claim the Life Support Concession.
For concession details and conditions, please see over.
NMI No. (if known – please refer to your bill): Water agency (haemodialysis machines only): If you pay a caravan park or retirement village for your electricity, please contact the Concessions Unit on 1800 658 521 to discuss your application.
Not eligible for concession (please Eligible for an electricity concession (please Continuous positive airways pressure (CPAP) machine Eligible for an electricity and a water concession: Date of installation: ……/……/…… Hospital/medical practitioner’s statement: I certify that the machine indicated is/will be installed in the patient’s home.
Signed:…………………………………………………………………………………………… (NB: Commonwealth Seniors Health Cards are not eligible) (Note: Cards marked ‘Dependant’ are not eligible) I verify that I have read all the conditions (overleaf) and that the information provided is correct.
Signed:…………………………………………………………………………………………… Please return this form to your electricity retailer or water agency. Addresses are overleaf.
Please notify the electricity retailer and/or water agency when the machine has been removed.
Process date: ………/………/……… The amount of the concession is equal to the cost of 1,880 kilowatt hours of electricity usage per annum, divided between • If you or someone in your household uses a life support machine, this form is used to notify your electricity and/or water company of the presence of the machine, to ensure If you use a haemodialysis machine, you can also receive a you are notified prior to any withdrawal of service that may concession off your water bills, equal to the cost of 168 kilolitres of water per annum, divided between your four quarterly bills.
• If the electricity/water account holder has an eligible concession card, and the life support machine used is an Please send your form to your electricity retailer or water agency.
eligible machine, you can also claim a concession on your Addresses for the major companies are given below. If your company is not listed, please contact the account enquiries • Pensioner Concession Card – issued by Centrelink or Completed all of your details, and your account details.
Asked your hospital social worker, or medical practitioner, to complete the hospital/medical practitioner section.
• Department of Veterans’ Affairs Gold Card (cards marked Commonwealth Seniors Health Cards, Victorian Seniors Card, The information on this form is required to assess your eligibility Child Disability and Foster Care Health Care Cards and for a rebate and may be verified by Centrelink or the Department Medicare Cards are not eligible cards.
of Veterans’ Affairs and will not be used for any other purpose What machines are eligible for a concession? without your consent. The information will be provided to yourelectricity/water retailer and/or distributor for the purpose of The life support machine must be one of the eligible machines listed below. Your hospital social worker or doctor must havecompleted the front of the form to confirm the installation The information will be securely stored within the Department of Human Services or your electricity/water retailer and/ordistributor. Only staff involved in processing your application will have access to the information provided on this form. The information will be retained only for the period required by the Public Records Act 1973. You are able to access your personal • Intermittent peritoneal dialysis machine information provided to the Department of Human Services andseek to correct this information or withdraw consent, if necessary.
Without the information requested, we are unable to access youreligibility and grant you the rebate.
Eligible machines are those that consume at least 1,880 kilowatthours of electricity per annum.
For further information, please contact your electricity retailer or water agency, or call the Concessions Information Line on 1800 658 521.
Published by Victorian Government, Department of Human Services, Melbourne, Victoria Copyright State of Victoria, Department of Human Services This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968.
Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne

Source: http://www.momentumenergy.com.au/system/files/documents/life_support_concession_jan_09-web_version.pdf