NDIS Assistive Technology Funding Request

NDIS Assistive Technology Funding Request

Participant Information

• Full name: Marcus Vance
• NDIS number: 430891274
• Date of birth: 14/05/1978
• Residential address: 42 Banksia Grove, Subiaco WA 6008
• Telephone: 0412 889 341
• Email address: m.vance78@email.com.au

Support Coordinator or Plan Manager Information (where relevant)

• Name: Sarah Jenkins
• Organisation: West Coast NDIS Coordination
• Telephone: (08) 9381 4420
• Email address: s.jenkins@wcndis.com.au

Assistive Technology Information

• Technology category: Personal Mobility Equipment (Mid-Cost AT)
• Intended purpose: Provide stable weight-bearing support for indoor and community ambulation, plus an integrated seat for fatigue management.
• Contribution to the participant’s goals: Facilitates independent community access and reduces falls risk, directly supporting the goal to independently attend local community group meetings and complete light grocery shopping.

Supplier Information

• Supplier: Perth Mobility & Rehab Solutions
• Contact person: David Thorne
• Telephone: (08) 9244 8810
• Email address: quotes@perthmobility.com.au
• Business address: Unit 4, 118 Osborne Park Road, Osborne Park WA 6017

Quotation Information

• Description of goods: Euro-style forearm support rollator (lightweight aluminium frame, adjustable forearm troughs, lockable handbrakes, integrated mesh seat, and front storage bag). Item code: MOB-FS400.
• Price: $1,450.00 (GST exempt)
• Expected delivery: 2 weeks from funding approval

Treating Health Professional Information

• Name: Liam O'Connor
• Professional role: Physiotherapist
• Registration number: PHY0001894321
• Telephone: (08) 9382 1190
• Email address: l.oconnor@perthneurophysio.com.au
• Practice address: 88 Rokeby Road, Subiaco WA 6008

Health Professional’s Supporting Recommendation

• Participant’s disability: Secondary progressive multiple sclerosis (SPMS) presenting with bilateral lower limb spasticity, ataxia, and significant motor fatigue.
• How the technology addresses the participant’s requirements: Standard 4-wheeled rollators are no longer suitable due to progressive UL weakness and poor grip strength. The forearm support channels allow proximal weight-bearing through the elbows, improving trunk alignment, reducing energy expenditure during gait, and mitigating falls risk (2 near-falls in the past month).
• Further remarks or recommendations: Successful 2-week trial completed in home and community settings. Request includes 1 hr physiotherapy funding ($193.99) for final ergonomic fitting and gait training upon delivery.

Participant Confirmation

• I confirm that, to the best of my knowledge, the details in this request are accurate and complete.
• Signature: Marcus Vance
• Date: 18/05/2024

Health Professional Confirmation

• I confirm that, to the best of my knowledge, the details in this request are accurate and complete.
• Signature: Liam O'Connor, APAM
• Date: 18/05/2024