Hospital Inpatient Assistance Application Form

HOSPITAL INPATIENT ASSISTANCE APPLICATION FORM
We understand that when you go to hospital you and your loved ones can have additional costs. These include extra food, car parking, mobile data and the need for good coffee. With repeated hospital admissions these can all add up. So at CFT we are aiming to provide you with some assistance to offset these costs.

Eligibility:
- Membership of CFT must be current;
- Available to all adults and children with CF;
- Available for hospitalisations of four consecutive nights or more.
Entitlement:

Hospital admissions for 4-9 nights:
- $100 per admission. Maximum of 3 per year; however, this will be reviewed on a case-by-case basis, plus
- Members with special, recognised dietary needs may be eligible for an additional $50 for the purchase of non-hospital food;
Hospital admissions for 10+ nights:
- $200 per admission. Maximum of 3 per year, however, this will be reviewed on a case-by-case basis;
  plus
- Members with special, recognised dietary needs may be eligible for an additional $100 for the purchase of non-hospital food;
Exemptions:

CF's Hospital Inpatient Assistance cannot be claimed for your period of hospitalisation for a transplant, as our transplant assistance covers this. However, pre and post-transplant hospital admissions can be claimed using Hospital Inpatient Assistance.

Process:

1. You can complete this form once you have started your hospital stay or are discharged.

2. The form can be filled out by someone else on your behalf, such as a loved one, CF Clinic staff member, or anyone else you nominate.

3. Lodge the form with CFT for your claim to be processed.
Name of person staying in hospital*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Post Code
Email address of member

Confirmation Emailexample@example.com
Mobile Number*

Phone Number
Name of Hospital*
Eg RHH, LGH, North West Regional Hospital
Date of admission*

DayMonthYear
If unsure just an approximate date
Approximate number of nights in hospital*
Eg 3, 5, 7, 10+
Does the patient have any identified dietary requirements?*

NoCoeliac/Gluten FreeDiabeticLactose FreeOther
Details of person completing this form (if different from above)

Name

Street Address Line 2

Relationship

Mobile Number
Email address of person completing the form

Confirmation Emailexample@example.com
BANK ACCOUNT DETAILS FOR PAYMENT OF FUNDS
Bank account holder*
Name
BSB*
Account Number*
Relationship to member with CF*
Eg self , parent, spouse etc.
DECLARATION

I declare that all information I have provided to Cystic Fibrosis Tasmania is true and accurate. I understand if it is found that I have knowingly provided false or inaccurate information I may no longer be eligible to be a member, or receive any or all of the services and benefits provided by Cystic Fibrosis Tasmania.

I also authorise Cystic Fibrosis Tasmania to contact any health professionals to verify the information provided in this application.
E-Signature Name*
Date*

DayMonthYear
Date
Should be Empty:

HOSPITAL INPATIENT ASSISTANCE APPLICATION FORM

Eligibility:

Exemptions: