General Criteria

1. The Mary Potter Foundation is administered by the Calvary Community Council (CCC) which assesses all applications.

2. Applications to the Mary Potter Foundation are made by accredited Medical Practitioners who recommend treatment or a procedure for those experiencing economic hardship. For the purposes of this application process, the CCC considers the accredited Medical Practitioner as the applicant.

3. The Mary Potter Foundation considers applications where a patient lacks capacity to pay due to some form of disadvantage or impaired social-economic circumstances acknowledged by the It invites patients to make a contribution to payment where possible.

4. If the patient does not have private health insurance the Calvary Community Council considers full or part payment of Calvary hospital charges.

5. If the patient does have some level of private health insurance the Calvary Community Council considers full or part payment of Calvary hospital charges above what is paid by the patient’s private health insurance.

6. It is the responsibility of the applying Medical Practitioner to ensure all other medical practitioners involved in the care of the patient agree to charge Medicare rates only.

7. The Foundation does not cover extra medical costs billed by third party medical suppliers such as (but not limited to) Pathology and Imaging services.

8. The Council approves requests for funding from a limited resource and for this reason is unable to fund the cost of prostheses.

9. If prostheses are required the applying Doctor is encouraged to negotiate arrangements with suppliers.

I declare I have read the criteria above

Please tick once the above criteria is read *

Before Commencing this Application you must acknowledge and agree to the following 4 points

I declare I am currently a Credentialed Medical Practitioner with Calvary Hobart or Calvary Launceston. *

It is the responsibility of the applying Medical Practitioner to ensure that ALL other medical practitioners involved in the care of the patient agree to charge Medicare rates only. *

The Foundation does not cover extra medical costs billed by third party medical suppliers such as (but not limited to) Pathology and Imaging services. *

I understand The Calvary Community Council is funded from a limited resource and for this reason is unable to fund the cost of any required Prosthetics. *

Funding Request

Requesting Doctor

Doctors Prefix

Doctors First Name

Doctor's Surname

Field of specialty

Best Email Contact

Best Mobile Contact

Practice Address

City

State

Postcode

Please select all Calvary locations you are currently credentialed with:

St John's - HobartLenah Valley - HobartSt Luke's - LauncestonSt Vincent's - Launceston

Your Patient's Details

This will not be disclosed to the Committee. All applications are anonymous and do not contain any identifying information.

Prefix

Patient Given Name

Patient Surname

Patient's best contact phone number should we have any queries to them regarding this application

Patient's DOB

Patient's Medicare Number

Does candidate have a Health Care Card?

YesNo

Does candidate have Private Health Cover?

YesNo

Does Candidate Receive a Pension?

YesNo

Has the medical condition resulted from a work related accident, disease or traffic accident?

YesNo

Public Health System: Can this treatment be accessed via the public health system? *

Give details If patient is on current waiting lists etc. or reasons why or why the public system not a viable option for this patient.

Please remember, for the following questions, please be as thorough and in depth as you can regarding the patients situation. The Calvary Community Council needs to be as well informed as possible about the financial constraints and personal challenges of your patient.

As notified earlier, The Mary Potter Foundation does NOT cover the costs of Prosthetic Devices. Will this application contain any prosthetic components? *

YesNo

Opening Statement - Please give a General Overview of Condition and proposed treatment options

Proposed Medical Treatment

Item Number

Brief Description of procedure

So we can obtain correct quotes

Proposed Medical Treatment

Item Number

Proposed Medical Treatment

Item Number

Proposed Medical Treatment

Item Number

Expected Length of Stay in Days

Will any Critical Care Days be required?

YesNo

Social Circumstances/Hardships if Applicable (Please detail)

Financial Circumstances/Hardships if Applicable (Please detail)

In your opinion, what is the medical urgency of this condition and the required procedure(s) *

Immediately - As soon as possible1 to 3 Month Timeframe3 to 6 months

Closing Summary or any further comments you wish to add

In there any supporting documentation you may wish to include for the committee? *

YesNo

Please send any supporting documents via email attachment to tas-hobart-executiveassistant@calvarycare.org.au with the following subject line:

Mary Potter Foundation Application | [YOUR NAME]

Date

Your Signature *

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