You may notice changes to this website as we work to make it easier to use.

Learn more and share feedback

Section A - Patient details

(HHS to complete)

Section B - Accommodation details

(HHS or accommodation provider to complete)

Accommodation type
(if commercial accommodation)
Did the patient and / or escort stay a different number of nights than were approved?
I declare that the number of nights claimed are a true reflection of the actual nights stayed by the approved patient and / or patient escort(s)
Date * (DD / MM / YY)
Section C - Approved patient / patient escort details

(HHS to complete)

patient details
Check-in date * (DD / MM / YY)
Check-out date * (DD / MM / YY)
patient escort details
Check-in date * (DD / MM / YY)
Check-out date * (DD/MM/YY)
Section D - Approving hospital details

(HHS to complete)

Section E - Patient declaration

(patient / guardian / patient escort to complete)

I confirm that I stayed in the accommodation over the period approve above. I agree for any accommodation subsidy for which I have been approved to be paid directly to the accommodation facility. I am aware that I am liable at checkout for the full cost of any additional accommodation not previously approved by my closest public hospital or health facility.

Date * (DD/MM/YY)
Date * (DD/MM/YY)
Hospital and Health Service use only

I, as the medical superintendent (or representative), authorise the above accommodation as required.

Date * (DD / MM / YY)