Doctor or Medical Practitioner Assessment

Who is the MPTP for?

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 travel on public transport; not mild or moderate.

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

• A person’s age
• Lack of available transport
• Eligibility to hold a driver licence

Please ensure that all sections of the form 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.

Comments

Applicant Details

Title --None-- Ms. Miss. Mrs. Mr.

First Name

Surname

Date of Birth (Day / Month / Year)

Gender --None-- Male Female

Phone number

Email

Confirm applicants email

Residental Address

Street Address

Suburb / Town

State --None-- VIC NSW ACT QLD TAS NT SA WA

Postcode

Postal Address

Is the applicant's Postal address the same as their residential address.

Street Address

Suburb / Town

State --None-- VIC NSW ACT QLD TAS NT SA WA

Postcode

Other Details

Does the applicant recieve a Centrelink benefit?

Yes No

Applicant's Centrelink number

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

Yes No

Applicant's Department of Veteran Affairs number

Medical Examination

Date of Examination: (Day / Month / Year)

Reason for completing this form --None-- Application for new membership Renewal Wheelchair/scooter update Medical update

Primary disability

Select the applicant's primary disability Please select category

Select the applicant's primary disability diagnosis (multiple diagnosis can be selected)

Please select a category first

Diagnosis of primary disability

Please provide aetiology (spell out acronyms)

Grade the severity of the disability with regards to its impact on the applicants ability to use public transport safely and independently --None-- Moderate Severe

Is the disability permanent?

Yes No

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?

Yes No

Please describe in full, the functional impact of the applicant’s disability in using public transport.

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?

Yes No

Wheelchair Scooter No

Select Secondary Disability (if required)

Does the applicant have a secondary disability that requires consideration?

Select the applicant's secondary disability Please select category

Select the applicant's secondary disability diagnosis (multiple diagnosis can be selected)

Please select a category first

Diagnosis of secondary disability

Please provide aetiology (spell out acronyms)

Grade the severity of the disability with regards to its impact on the applicants ability to use public transport safely and independently --None-- Moderate Severe

Is the disability permanent?

Yes No

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?

Yes No

Please describe in full, the functional impact of the applicant’s disability in using public transport

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

Title --None-- Dr. Ms. Miss. Mrs. Mr.

First Name

Surname

Employer / Business Name

In what capacity is this assessment made (please select) --None-- Medical practitioner Psychologist Psychiatrist Optometrist Opthalmologists

AHPRA number

Business street address

Business suburb

Business state --None-- VIC NSW ACT QLD TAS NT SA WA

Business postcode

Business phone

Business email

Confirm Doctors email

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.

By ticking this check box, I confirm that I have read and understood all the statements above.

Full name of medical practitioner completing this application