Equipment prescription form

Health providers can use this form to request equipment for injured employees.


What it contains

Service providers can use this form to request wheelchairs, pressure cushions, powered conversion kits, hoists, scooters, beds, mattresses, standing frames, tilt tables, large exercise equipment, lounge chairs and customised chairs.

The form should also be used to request repairs or modifications to this equipment.

Details to be completed in the form include:

  • the injured employee's details
  • equipment details, including if it's to be reissued, replaced, modified or purchased
  • the employee's work-related injuries and medical history
  • what type of equipment is recommended and how it will benefit the employee
  • It is expected that prescribing therapists conduct trial of items with WorkSafe equipment contracted suppliers before recommending any non-contracted items from an alternative supplier in line with the WorkSafe Equipment and related services policy
  • anticipated maintenance and repair, training requirements and the treating therapist's details

A valid quote for the recommended equipment must be submitted in conjunction with the correctly completed equipment prescription form.