PTAS Application Form
PATIENT TRAVEL ASSISTANCE SCHEME (PTAS)	

The Patient Travel Assistance Scheme (PTAS) helps cover your travel costs if you need to travel long distances to access specialised health care. More information is provided in the attached Summary Guide.
Detailed information can be found at www.health.tas.gov.au/ptas.
Section 1: Patient to complete	
Section 1 must be completed and signed by the patient or their guardian/carer. Your personal information will only be used to process your PTAS Application and will be managed in accordance with the Personal Information Protection Act 2004	
Patient's contact and personal information	
Patient's name	<<Patient Demographics:First Name>>	Date of birth	<<Patient Demographics:DOB>>	
Residential address	<<Patient Demographics:Address Line 1>>	
Suburb	<<Patient Demographics:City>>	Postcode	<<Patient Demographics:Postcode>>	
Postal address	<<Patient Demographics:Address Postal>>	
Suburb	<<Patient Demographics:Address Postal City>>	Postcode	<<Patient Demographics:Address Postal Postcode>>	
Preferred contact method	<<Patient preferred contact method>> 	
Home phone	<<Patient Demographics:Phone (Home)>>	Mobile 	<<Patient Demographics:Phone (Mobile)>>	
Email	<<Patient Demographics:E-mail>>	
Ethnicity	<<Patient Demographics:ATSI>>	
Appointment details (if known)	
Please provide a copy of your appointment letter with your application.	
Concession card copy (if you have one)   <<Does the patient have a concession card?>>	
Please provide a copy of your current concession card with your application.	
Payment details (reimbursement is by electronic funds transfer)	
Account name		
BSB number (6 digits)		Bank		
Account number		
Declaration and consent	
•	I am not eligible to receive financial assistance for travel expenses from a private health fund or any other scheme including the National Disability Insurance Scheme, Department of Veterans’ Affairs, Motor Accidents Insurance Board, or workers compensation.
•	I give permission for my doctors to share relevant information with the PTAS Medical Authoriser.
•	I understand that I must submit Section 3 of this form within 6 months of the first date of treatment.	
Signature of patient or parent/guardian		Date		

Section 2: 	Referring medical practitioner to complete	
•	Section 2 must be completed and signed by the referring medical practitioner.
•	The referring medical practitioner must describe the treatment for which the patient is being referred with sufficient detail to enable assessment of PTAS eligibility by the Medical Authoriser (a medical practitioner).	
Patient details	
Patient name	<<Patient Demographics:Full Name>>	
Date of birth	<<Patient Demographics:DOB>>	Phone Number	<<Patient Demographics:Phone (Mobile)>>	
Address	<<Patient Demographics:Full Address>>	
Referring medical practitioner details (doctor who is referring the patient to a specialist). 
For travel outside of Tasmania, the referring doctor must be a Tasmanian specialist.	
Name	<<Doctor:Name>>	Provider number	<<Doctor:Provider Number>>	
Address	<<Doctor:Address>>	
Telephone	<<Doctor:Phone>>	Email	<<Doctor:E-mail>>	
Nominated clinical provider details (clinician whom the patient is travelling to see) 
Travel to private clinical services outside of Tasmania is not eligible for PTAS subsidies.	
Name	<<Name of clinician patient is travelling to see>>	Type of specialist	<<Type of specialist patient is travelling to see >>	
Address	<<Address of clinician patient is travelling to see>>	
Telephone	<<Phone number of clinican patient is travelling to see>>	Email	<<Email of clinician patient is travelling to see>>	
Detailed reason for referral (this information is essential for assessing PTAS eligibility)	
<<Detailed reason for referral (essential for PTAS)>>	
Can this procedure be undertaken in Tasmania?	<<Can this procedure be undertaken in Tasmania?>>	
Is this the nearest specialist?	<<Is this the nearest specialist?>>	
If no, please provide reason	<<If no, please provide reason>>	
Are special travel arrangements needed for medical reasons?	<<Are special travel arrangements needed?>>	
If yes, please specify	<<If yes to special arrangements please specify>>	
If other, please specify	<<If other, please specify>>	
Escort details (if applicable) (Escort must be 18 yers of age or older)	
Does the patient require assistance by an escort?	<<Does the patient require assistance by an escort?>>	
If yes, please provide medical reason	<<Medical reason for requiring escort (please detail)>>	
Escort name	<<Escort name>>	
Date of birth	<<Escort date of birth>>	Mobile phone	<<Escort mobile phone number>>	
Signature of referring medical practitioner		Date		

Office use only	PTAS:		Approved		Not approved	Escort		Approved		Not Approved	
		
Reason / Comments		
Signature of medical authoriser		Date		
Print Name		

Section 3: 	Approved clinical provider to complete 	
•	Section 3 must be completed and signed by the approved clinical provider or their authorised officer (for example, registrar, intern, nurse unit manager, or clinical technician, who works directly with them).
•	‘Dates of services’ must be updated and signed at each appointment.
•	The patient or their guardian/carer must return a copy of this form to the local PTAS office within 6 months of the date of service.	
Patient Details	
Name	<<Patient Demographics:Full Name>>	Date of birth	<<Patient Demographics:DOB>>	
Clinical provider’s details (not name of authorised officer)	
Name		
Type of specialist		Provider no. 		
Description of consultation or procedure undertaken 	

Dates of stay for medical reasons	From		To		
Dates of inpatient stay (if applicable)	From		To		
Certification by clinical provider or authorised officer	
Name		
Position		
Telephone		Email		
Signature of clinical provider or authorised officer		Date		

Dates of services (complete when attending multiple appointments)	
Length of stay	Procedure	Clinical provider’s signature	
Dates			
From	To	Appointment time	(For example. consultation, pre-admission, surgery, post-op)		

					

					

					

	Summary guide
PATIENT TRAVEL ASSISTANCE SCHEME (PTAS)	

This guide is intended to be read together with the attached PTAS application form.
If you need more information
Visit	 www.health.tas.gov.au/ptas 
Call	your local PTAS office:	South	6166 8225
North	6777 6249
North West	6477 7734	

What is the Patient Travel Assistance Scheme?
Travelling for specialised health services can be costly if you live a long way from the care you need. The Patient Travel Assistance Scheme (PTAS) may help you with travel costs for transport and accommodation, and for a support person if you need physical assistance while travelling.
Who can receive a PTAS subsidy?
You may be eligible for PTAS financial help if you:
•	are a Tasmanian resident
•	are receiving an eligible clinical service from an approved clinical provider
•	need to travel more than 75 km one-way to the nearest specialised health service OR for patients undergoing treatment such as dialysis, oncology or for haematological malignancy, more than 50 km one-way or where travel is equal to or greater than 150km over a 4 week period to access the nearest appropriate treatment centre for oncology, haematological malignancies or renal dialysis.
What services are eligible?
You can receive a travel subsidy for these services:
•	most specialist medical services provided by the Tasmanian public hospital system or covered under Medicare
•	some interstate medical services, if the service isn’t available in Tasmania 
•	oncology, haematological malignancy, or dialysis treatment
•	lymphoedema treatment in Tasmania referred by an oncologist or general surgeon
•	Jack Jumper Allergy Program
•	allied health services ordered by a specialist as part of an eligible service treatment plan
•	independent midwifery services for women who have a low-risk or uncomplicated pregnancy
•	Pre-implantation Genetic Diagnosis (PGD) where there is a known genetic disorder in a family and for which PGD is available.
•	Referral for termination services not available in Tasmania (Part 2 may be completed by a GP). 
Some dental services (e.g. severe dental trauma or infection, specialist management required due to significant medical co-morbidity). 
How do I apply?
Complete the attached application form. You can download another application form from www.health.tas.gov.au/ptas
About your application
•	You must complete a separate application for each service provider you are seeing. 
•	You must submit your claim within 6 months of your first appointment date.
•	If you see the same provider several times a year, Section 2 of your application is valid for 12 months. A copy of Section 1 and 3 must be updated and lodged for each claim.
•	Once your application is approved we will contact you about any flight bookings. These bookings can be made by staff. 
•	If you make your own bookings and claim for reimbursement afterwards, please check if you are eligible for a subsidy before you book.
How much are the subsidies?
The subsidy rates are in the table below.
Patients who do not hold an approved concession card must pay:
•	 the total cost of the first 2 nights’ accommodation per journey and
•	the first $82.50 towards the cost of each return journey. 
Patient contributions are capped at $330 per financial year.
Subsidies may not cover all expenses. All patients must pay any difference between the subsidy amount and the actual cost of travel and accommodation.
Approved concession cards
•	Services Australia Pensioner Concession Card (PCC)
•	Services Australia Health Care Card (HCC)
•	Department of Veterans’ Affairs Pensioner Concession Card (DVA PCC)
Commonwealth Seniors Health Card is not an approved concession card.
The Concession card must be in the patient’s name to be eligible (does not apply to paediatric patients).  
 
Service	Tasmania	Interstate	
Air	Economy fare	Economy fare	
Ferry/bus	Best available fare	Best available fare	
Private car	$0.24 per km	Not applicable.	
Taxi	Between airport and place of treatment.	For travel between airport and place of treatment only.	
Accommodation	Up to $77.60 per approved person, per night (accommodation subsidies do not apply to inpatients) 	Up to $100 per approved person, per night (accommodation subsidies do not apply to inpatients)  	

Send your completed application to your local PTAS office	
South
Royal Hobart Hospital
PO Box 1061 
HOBART  TAS  7001
Phone: 6166 8225
Email: ptasrhh@ths.tas.gov.au	North
Launceston General Hospital
PO Box 1963 
LAUNCESTON  TAS  7250
Phone: 6777 6249
Email: lgh.patient.travel@ths.tas.gov.au	North West
North West Regional Hospital
PO Box 258
BURNIE  TAS  7320
Phone: 6477 7734
Email: nw.ptas@ths.tas.gov.au	

Check that your application form is ready!
•	Section 1 has been completed and signed by the patient or their guardian or carer.
•	A copy of the patient’s concession card is attached (if applicable).
•	Section 2 has been completed and signed by the referring medical practitioner.
•	Section 3 has been completed and signed by the clinical service provider or an authorised officer.
•	Each ‘dates of service’ entry in Section 3 has been signed by the provider or their authorised officer.
•	Receipts or tickets are attached for all travel for the patient and their escort (if approved). 
(Not required for private car fuel.)
•	Tax invoices for accommodation are attached and include names of persons accommodated and costs 	

Detailed information about PTAS can be found at www.health.tas.gov.au/ptas.