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Travel application (Form B)

Patient Travel Subsidy Scheme (PTSS)

Travel application (Form B)

Privacy statement

Personal information collected by Queensland Health is handled in accordance with the Information Privacy Act 2009. Your personal information is being collected in order to assess whether you are eligible to receive a subsidy under the Patient Travel Subsidy Scheme. The personal information provided by you will be securely stored and made available to appropriately authorised officers of Queensland Health. Personal information recorded on this form will not be disclosed to other parties without your consent, unless the disclosure is authorised or required by or under law. For information about how Queensland Health protects your personal information, or to learn about your right to access your own personal information, please refer to our Privacy Policy.

PTSS travel is assessed per the eligibility criteria (published in the PTSS guideline) and approved by individual Hospital and Health Services.

Section A - Patient details
Date of birth * (DD / MM / YY)
Expiry date * (MM / YY)
Are you of Aboriginal and/or Torres Strait Islander origin?
Section B - Patient escort details

(referring clinician or nominated representative to complete)

Is the patient applying for an escort?
Escort details
Date of birth * (DD/MM/YYYY)
Clinical reason for escort: An escort is medically required for the following reason/s
Does the escort require accommodation?
Section C - Treating specialist details

(where patient is being referred to)

Travel application is valid for 12 months (subject to review at any time)

Clinical trial?
(include reason for referral)
Is this the patient's closest specialist?
Section D - Reason for travel

(referring or nominated clinican to complete)

Appointment type:
This condition may require ongoing travel for appointments
Date (DD/MM/YYYY)
Time (HH:MM)
Clinically recommended mode of travel
Cllinical reason for selected mode of travel (based on patient's circumstances) Mode of travel defaults to the most economical mode if adequate information (e.g. clinical reason) is not provided.
Patient is not medically advised to travel via other travel modes due to
Other reasons may include: Medical condition / patient's age / time of the appointment / length of travel time / to ensure patient's safety on arrival and access to accommodation (provide clinical reason below).
Section E - Accommodation

(referring clinican or nominated representative to complete)

Is the patient applying for a subsidy for accommodation?
(e.g. clinical reason to stay after appointment or discharge date, accommodation preference, etc.)
Section F - Declaration

Referring clinician (or clinician's nominated representative) declaration:

I certify that the information provided on this form is correct. I have advised the patient or guardian / carer that Hospital and Health Service staff may contact the referring facility and travel / accommodation providers regarding this referral.

Date * (DD / MM / YY)
Hospital and Health Service use only - Approval
Subsidy approved for travel to
Mode of travel approved
Patient escort approved
Accommodation approved
Accommodation approved
Has it been determined if a telehealth alternative exists for this patient?
Hospital and Health Service approval
Date * (DD/MM/YY)
Date * (DD/MM/YYYY)