External Provider Request For Service

EXTERNAL PROVIDER REQUEST FOR SERVICE

This form follows an automated workflow: once submitted, it is routed to the AkinCare Service Leader for formal approval. Upon approval, the details provided below will be transmitted exactly as written to the external provider.To ensure prompt processing and minimize rework, please provide a clear, professional, and detailed description of the purpose and scope of the services. Accuracy is essential, as this information serves as the primary instruction for the service provider and constitutes a formal commitment by AkinCare to fund the services requested. Please treat this submission with the same due diligence as an official Work Order.
Person Completing This Form

These are the details of the person completing the form, normally an AkinCare staff member or Care Manager, Requesting services for a client to be paid for or billed to AkinCare.
Your Position:
Your Name:
Your Email:
example@example.com
CLIENT INFORMATION
Client Name:
Full Name
Client Phone Number:
Clients Best Contact Number
Date of Birth:

DayMonthYear
Date
Email:
example@example.com
Gender:
Emergency Contact:
Who should the provider contact if they cant get ahold of the client
Service Delivery Address:
Suburb:
Postcode:
Aged Care/NDIS or AkinCare Reference#
Service Provider

Who are you sending this request to?
Provider Business Name:
Eg; Top Nosh, Meals on Wheels, CareAlert Etc
Provider Email:
Where should we email this request to?
REQUESTED SERVICES
What services are you requesting for this client?
Please be specific and include price limits etc if relevant.
Billing Notes:
Service Request Validation & Disclosure

Instructions for Staff: Please review the following statements carefully. By submitting this request, you are providing a formal declaration of clinical and financial appropriateness and are in the clients best interest.
Staff Declaration

I,{yourName}, hereby confirm that I have reviewed the details of this service request and attest to the following:

Reasonable and Necessary: The requested service/item is directly related to {clientName}’s disability, aged care or healthcare needs and represents the most cost-effective way to achieve the desired outcome.

Care Plan Alignment: This request is consistent with the goals, strategies, and interventions outlined in {clientName}’s current Individual Care Plan.

Budgetary Compliance: I have verified the client's current funding balance. This request falls within the allocated budget and will not result in an unauthorized overspend of {clientName}'s package.

Conflict of Interest: I declare that I have no personal or financial interest in the provider or vendor being utilized for this service.
Signature
Should be Empty:

EXTERNAL PROVIDER REQUEST FOR SERVICE

Person Completing This Form

CLIENT INFORMATION

Service Provider

REQUESTED SERVICES

Service Request Validation & Disclosure