Funding & Ex Gratia Payments
St Vincent's Private Hospital Northside
Ex Gratia payment request process
Non PL listed prosthetics and high-cost consumables
Funding from Private Health Insurers may be available for prosthetics that are not listed on the Commonwealth Prostheses List and for high-cost consumables.
To allow sufficient time for Health Fund review and response, requests must be submitted at least 10 business days prior to admission.
Required Documentation
The documents listed below must be provided to the Revenue Team, who will submit the request to the relevant Health Fund on your behalf. Please email all documentation to: revenue@svha.org.au
- A letter from the admitting doctor that includes:
Why a listed prosthesis cannot be used or will not sufficiently meet the requirements of the procedure.
Supporting clinical documentation for the prosthesis or consumable. Suppliers can often assist with providing this information. - Completed Health Fund application form
Each Health Fund has its own application form.
If you are unsure which form is required, please contact the Revenue Team by emailing revenue@svha.org.au for assistance. - A supplier quote
A quote from the supplier for the prosthetic or high-cost consumable being requested.
Health Fund Application Forms
The following Health Fund application forms are available for download. Please complete the appropriate form and submit it with your supporting documentation to the Revenue Team. The Revenue Team will then submit the application to the relevant Health Fund on your behalf.
Health Fund Forms:
- Generic SVHA - Ex gratia template
- HCF - Ex gratia application form
- HCF - Application for special consideration of payment for drugs and devices
- MEDIBANK - Blank HCD application form
- NIB - HCD application form
- AHSA - high host medical device application form
- Bupa - Hospital editable form
- Bupa - High cost drug form
- DVA - Prior approval template