NDIS Access Request Form

NDIS Access Request – GP Supporting Evidence Template Patient Details: - Name: [patient full name] (Insert the patient’s full legal name. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Date of Birth: [date of birth] (Insert in DD/MM/YYYY format. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Address: [patient address] (Insert the patient’s residential address. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - NDIS Application Number: [NDIS application number] (Insert the NDIS application number if available. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Treating Professional Details: - Name: [clinician full name] (Insert your full name. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Qualification(s): [clinician qualifications] (Insert your relevant professional qualifications. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Provider Number: [provider number] (Insert your Medicare provider number. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Practice Address: [practice address] (Insert the full address of your practice. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Contact Number: [contact number] (Insert your preferred contact number. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Email: [email address] (Insert your professional email address. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Duration of Treatment: [duration of treatment] (Specify how long you have treated the patient. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Primary Disability: - [primary disability diagnosis] (Insert the primary diagnosis relevant to the NDIS application. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Date of Diagnosis: [diagnosis date] (Insert the date the primary disability was diagnosed. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Is the condition permanent? [Yes/No] (State whether the condition is considered permanent. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Is the condition likely to be lifelong? [Yes/No] (State whether the condition is expected to be lifelong. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Secondary Disabilities (if any): - [secondary disability diagnoses] (Insert any relevant secondary disabilities. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medical History: - [relevant medical and surgical history] (Summarise any relevant medical or surgical history that relates to the primary or secondary disabilities. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [relevant family history] (Insert family history that contributes to the disability or ongoing condition. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [relevant social history] (Include social history elements such as smoking, alcohol use, drug use, or occupational exposures. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [allergies and reactions] (Insert relevant allergies and any significant reactions. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [current medications] (List current medications the patient is taking. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [immunisation history] (Insert a summary of immunisation status if relevant. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [other relevant history] (Insert any other history that contributes to the functional impact or eligibility for NDIS. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Functional Impact: (Please describe how the patient's disability impacts the following areas. Only include sections explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Mobility: [impact on mobility] (Describe any difficulties with walking, balance, stamina, or need for assistive devices. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Communication: [impact on communication] (Include any issues with speech, language, understanding others, or expressing thoughts. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Social Interaction: [impact on social interaction] (Describe challenges with forming or maintaining relationships, regulating emotions, or social awareness. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Learning: [impact on learning] (Outline cognitive challenges including understanding new concepts, literacy, memory, or planning. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Self-Care: [impact on self-care] (Include challenges with hygiene, dressing, feeding, or toileting. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Self-Management: [impact on self-management] (Describe difficulties with making safe decisions, managing finances, attending appointments, or medication adherence. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Treatment History: - Previous Treatments: [previous treatments and outcomes] (List previous treatments attempted and their effectiveness. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Current Treatments: [current treatments and responses] (List current treatment modalities and their effectiveness. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Future Treatment Options: [future treatment plans] (Describe any proposed treatment options and their intended benefit. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Additional Information: - [additional disability-related information] (Insert any other relevant clinical details that support the NDIS application. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Declaration: I, [clinician full name] (Insert your full name. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely), confirm that the above information is accurate to the best of my knowledge and based on my professional assessment of [patient full name] (Insert patient’s full name. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely). Signature: Date: [date of completion] (Insert the date the document was completed. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that the information has not been explicitly mentioned in your output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)