This form must be completed for the TAC to consider requests for a variety of equipment, including wheelchairs, press cushions, powered conversions kits, hoists, scooters, bikes and recumbent trikes, beds, mattresses, standing frames, tilt tables, treatment couches, large exercise equipment, lounge chairs and custom toilet/shower/commode chairs. The separate 'notes' document in this section provides additional instructions and clarification to help complete the form.
If you are requesting complex items that require customisation, you will also be required to attach a standardised quote from the equipment supplier to the Equipment Prescription Form. The equipment supplier can either use the Equipment Prescription Form Quote Template or they can use their own business format as long as it supplies the same information as our template. A seperate 'notes' document is also available which provides detailed instructions to assist the supplier complete the quote template.
The TAC is unable to send or receive hard copy documents at this time. Please email forms or other documents to firstname.lastname@example.org and include the client's claim number in the subject line.