Prescription and Request Forms

Equipment needs to be ordered using a prescription form. Select the correct form, depending on the funding that is being used and the category of the item.

• Equipment Request Form - DHS Equipment Program (DOCX 180.2 KB)
• Home Modification Request and Agreement Form - DHS Equipment Program (DOCX 97.2 KB)

Category 2 items also require:

• Delegate approval form
• Risk Rating and Priority Scoring Form OR Priority Scoring Communication and Assistive Technology.

Additional forms (for example, screening tool, specification form) may also be required for more complex prescriptions. This enables the appropriate item to be provided to meet the person’s needs.

All prescription and request forms can be faxed to 1300 295 839 or emailed to DHSEquipmentProgram@sa.gov.au.