Project Colleague Funding Request Form

General Criteria

1. The Mary Potter Foundation is administered by the Calvary Community Council (CCC) which assesses all applications.

2. Applications to the Mary Potter Foundation are made by accredited Medical Practitioners who recommend treatment or a procedure for those experiencing economic hardship. For the purposes of this application process, the CCC considers the accredited Medical Practitioner as the applicant.

3. The Mary Potter Foundation considers applications where a patient lacks capacity to pay due to some form of disadvantage or impaired social-economic circumstances acknowledged by the It invites patients to make a contribution to payment where possible.

4. If the patient does not have private health insurance the Calvary Community Council considers full or part payment of Calvary hospital charges.

5. If the patient does have some level of private health insurance the Calvary Community Council considers full or part payment of Calvary hospital charges above what is paid by the patient’s private health insurance.

6. It is the responsibility of the applying Medical Practitioner to ensure all other medical practitioners involved in the care of the patient agree to charge Medicare rates only.

7. The Foundation does not cover extra medical costs billed by third party medical suppliers such as (but not limited to) Pathology and Imaging services.

8. The Council approves requests for funding from a limited resource and for this reason is unable to fund the cost of prostheses.

9. If prostheses are required the applying Doctor is encouraged to negotiate arrangements with suppliers.
I declare i have read the criteria above *

Please tick once the above criteria is read

Before Commencing this Application you must acknowledge and agree to the following 4 points *

I declare I am currently a Credentialed Medical Practitioner with Calvary Hobart or Calvary Launceston. It is the responsibility of the applying Medical Practitioner to ensure that ALL other medical practitioners involved in the care of the patient agree to charge Medicare rates only. The Foundation does not cover extra medical costs billed by third party medical suppliers such as (but not limited to) Pathology and Imaging services. I understand The Calvary Community Council is funded from a limited resource and for this reason is unable to fund the cost of any required Prosthetics.

Funding Request

Requesting Doctor
Doctors Prefix
Doctors FIrst Name
Doctors Surname
Field of Specialty
Best Email Contact
Best Mobile Contact
Practice Address
City
State
Postcode
Please Select all Calvary locations you are currently Credentialed with

St. John's - Hobart Lenah Valley - Hobart St. Luke's - Launceston St. Vincent's - Launceston

Your Patient's Details

This will not be disclosed to the Committee. All applications are anonymous and do not contain any identifying information.
Administration Staff preparing this document will be the only party able to view the next page of personal information.
Prefix
Patient Given Name
Patient Surname
Patient's best contact phone number should we have any queries to them regarding this application.
Mobile Preferred
Patient DOB

Day Month Year
Patients Medicare Number

Does candidate have a Health Care Card ?
Please Enter Health Care Card No
Does candidate have Private Health Cover ?
Please Enter Fund & Member No.
Does Candidate Receive a Pension
Pension Card No.
Has the medical condition resulted from a work related accident, disease or traffic accident ?

Yes No
If yes, what is the reason why money from that source is not available to cover the costs of the treatment.
Has a claim for damages, MAIB benefits or Workers Compensation benefits been made in relation to the medical condition?

Yes No
If yes, what is the reason why money from that source is not available to cover the costs of the treatment.
Public Health System: Can this treatment be accessed via the public health system? *
Give details If patient is on current waiting lists etc. or reasons why or why the public system not a viable option for this patient.

Please remember, for the following questions, please be as thorough and in depth as you can regarding the patients situation. The Calvary Community Council needs to be as well informed as possible about the financial constraints and personal challenges of your patient.

As notified earlier, The Mary Potter Foundation does NOT cover the costs of Prosthetic Devices. Will this application contain any prosthetic components? *
As you have answered YES to the Prosthetic Component, please detail how will this aspect of the procedure be funded (Patient, Company Sponsorship, other) as the Mary Potter Foundation is unable to fund this aspect.
Opening Statement - Please give a General Overview of Condition and proposed treatment options
Proposed Medical Treatment
Brief Description of procedure
Item Number
So we can obtain correct quotes
Proposed Medical Treatment
Brief Description of procedure
Item Number
So we can obtain correct quotes
Proposed Medical Treatment
Brief Description of procedure
Item Number
So we can obtain correct quotes
Proposed Medical Treatment
Brief Description of procedure
Item Number
So we can obtain correct quotes
Expected Length of Stay in Days
Will any Critical Care Days be required ?
If yes to ICU/Critical Care Days, please elaborate
Social Circumstances/Hardships if Applicable (Please detail)
Financial Circumstances/Hardships if Applicable (Please detail)

In your opinion, what is the medical urgency of this condition and the required procedure(s) *

Immediately - As soon as possible 1 to 3 Month Timeframe 3 to 6 months
Closing Summary or any further comments you wish to add *
In there any supporting documentation you may wish to include for the committee?
Date

Day Month Year
Date
Your Signature (or Type Name Under Box - if you do not have a touch Screen)

Clear
or If unable to E-Sig - Doctor Name

First Name Last Name
Should be Empty:

Funding Request

Your Patient's Details