Doctor or Medical Practitioner Assessment

Do you need to complete this form?

Assessment to be completed by the applicant’s regular medical practitioner, psychologist / psychiatrist, optometrist / ophthalmologists may complete for vision related disabilities.

The MPTP assists Victorians who are prevented from independently using public transport because of a severe and permanent disability. People are only eligible for the MPTP if their disability is.

  • Permanent – for the term of a person’s life and not expected to improve
  • Severe – of a type that severely limits mobility and safe and independent on public transport; not mild or moderate.

Factors which cannot be taken into consideration in determining eligibility include:

  • A persons age
  • Lack of available transport
  • Eligibility to hold a driver licence

Please ensure that all sections are completed to prevent the application being returned to you and delaying the processing of the application. Your complete answers to the questions are critical in the assessment of the applicant’s eligibility.

Applicant Details

Residental Address

Postal Address

Other Details

Does the applicant recieve a Centrelink benefit?
Does the applicant recieve a Department of Veterans Affairs (DVA) benefit?

Medical Examination

Primary disability

Select the applicant's primary disability diagnosis (multiple diagnosis can be selected)
Please select a category first

Diagnosis of primary disability

Is the disability permanent?
Is the disability likely to improve with medical treatment, such as further surgery, to the extent the applicant will be able to travel on public transport safely and independently?
Does the applicant permanently (being for the term if their life and not expected to improve) require the use of a wheelchair and /or scooter for mobility outside the home?

Select Secondary Disability (if required)

Doctor’s or medical practitioner’s details (personal details)

Acknowledgement

I understand and acknowledge that:

  • The information provided in this application is true and complete to the best of my knowledge.
  • Safe transport Victoria may refuse this application if it becomes evident that any information or supporting documents provided is incomplete and false.
  • I am not the applicant or an immediate family member of the applicant.
  • This application may be referred to health professional / MPTP panel for further assessment and review.
  • I agree to offer all reasonable assistance and records to assist Safe transport Victoria the MPTP panel or its nominated representatives to determine the applicant’s eligibility.