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Life support concession application form
Life Support Concession/Notification of installation of life support machine
Does a member of your household use a life support machine?
All households with life support users should complete this form to ensure their electricity retailer and/or water authority are awareof the presence of a Life Support machine at their residential address.
If the electricity and/or water account holder holds an eligible concession card, they can also claim the Life Support Concession.
For concession details and conditions, please see over.
NMI No. (if known – please refer to your bill
Water agency (haemodialysis machines only
If you pay a caravan park or retirement village for your electricity, please contact the Concessions Unit on 1800 658 521 to discuss your application.
Not eligible for concession (please
Eligible for an electricity concession (please
Continuous positive airways pressure (CPAP) machine
Eligible for an electricity and a water concession:
Date of installation: ……/……/……
Hospital/medical practitioner’s statement:
I certify that the machine indicated is/will be installed in the patient’s home.
(NB: Commonwealth Seniors Health Cards are not eligible)
(Note: Cards marked ‘Dependant’ are not eligible)
I verify that I have read all the conditions (overleaf) and that the information provided is correct.
Please return this form to your electricity retailer or water agency. Addresses are overleaf.
Please notify the electricity retailer and/or water agency when the machine has been removed.
Process date: ………/………/………
The amount of the concession is equal to the cost of 1,880 kilowatt hours of electricity usage per annum, divided between
• If you or someone in your household uses a life support
machine, this form is used to notify your electricity and/or water company of the presence of the machine, to ensure
If you use a haemodialysis machine, you can also receive a
you are notified prior to any withdrawal of service that may
concession off your water bills, equal to the cost of 168 kilolitres
of water per annum, divided between your four quarterly bills.
• If the electricity/water account holder has an eligible
concession card, and the life support machine used is an
Please send your form to your electricity retailer or water agency.
eligible machine, you can also claim a concession on your
Addresses for the major companies are given below. If your
company is not listed, please contact the account enquiries
• Pensioner Concession Card – issued by Centrelink or
Completed all of your details, and your account details.
Asked your hospital social worker, or medical practitioner,
to complete the hospital/medical practitioner section.
• Department of Veterans’ Affairs Gold Card (cards marked
Commonwealth Seniors Health Cards, Victorian Seniors Card,
The information on this form is required to assess your eligibility
Child Disability and Foster Care Health Care Cards and
for a rebate and may be verified by Centrelink or the Department
Medicare Cards are not eligible cards.
of Veterans’ Affairs and will not be used for any other purpose
What machines are eligible for a concession?
without your consent. The information will be provided to yourelectricity/water retailer and/or distributor for the purpose of
The life support machine must be one of the eligible machines
listed below. Your hospital social worker or doctor must havecompleted the front of the form to confirm the installation
The information will be securely stored within the Department
of Human Services or your electricity/water retailer and/ordistributor. Only staff involved in processing your application
will have access to the information provided on this form.
The information will be retained only for the period required by the
Public Records Act 1973
. You are able to access your personal
• Intermittent peritoneal dialysis machine
information provided to the Department of Human Services andseek to correct this information or withdraw consent, if necessary.
Without the information requested, we are unable to access youreligibility and grant you the rebate.
Eligible machines are those that consume at least 1,880 kilowatthours of electricity per annum.
For further information, please contact your electricity retailer or water agency, or call the
Concessions Information Line on 1800 658 521.
Published by Victorian Government, Department of Human Services, Melbourne, Victoria
Copyright State of Victoria, Department of Human Services
This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968
Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne
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