SPORTS MEDICINE AND PHYSIOTHERAPY HANDBOOK

Transcription

1 SPORTS MEDICINE AND PHYSIOTHERAPY HANDBOOK August 2012 NTIS Sports Medicine and Physiotherapy Coordinator Ph: (08) Greg Dea Fax: (08) NTIS Athlete Services Manager Ph: (08) Michael Watkins Fax: (08) This document and all documents in the Appendices of this booklet, along with all NTIS policies and guidelines can be found on the NTIS website - Please do not hesitate to contact the NTIS s Sports Medicine and Physiotherapy Coordinator with any questions or concerns. 1

2 CONTENTS Sports Medicine and Physiotherapy Coordinator Welcome Page 3 General Sports Medicine Principles Page 3 Vaccination/ Immunisation Page 3 Pre-participation Athlete Medical Screening Page 4-5 Musculoskeletal Screening Process Page 6 Sports Medicine Clinic/ Servicing Page 6 Access to other Medical/ Allied Health service providers Page 7 Injury Notification Responsibilities Page 7 Injury Management by Club Personnel Page 7 Darwin Region Injury Management Flow Chart Page 8 Southern Region Athletes Page 8 Southern Region Injury Management Flow Chart Page 9 Single Sport Page 10 Reimbursement of Medical Expenses Page 10 Post Scholarship Injury Management Page 11 Athlete Education Sessions Page 11 Other NTIS Sports Medicine Policies Page 11 Failure to comply with NTIS Sports Medicine and Physiotherapy Coordinator Recommendations Page 11 Appendix 1: Schedule of Sports Medicine Services Page 12 Appendix 2: NTIS Athlete Injury Notification Form Page 13 Appendix 3: NTIS Medical Expense Reimbursement Claim Form Page 14 Appendix 4: NTG GAS (Government Accounting System) Page 15 Payment Details Individual/ Non-Business 2

3 Sports Medicine and Physiotherapy Coordinator (SMPC) Welcome Congratulations on being awarded with a Northern Territory Institute of Sport (NTIS) scholarship! This resource is designed to give you a better understanding of the Sports Medicine and Physiotherapy services available through the NTIS. It aims to provide a summary of how to go about accessing these services, as well as highlighting individual s responsibilities in doing so. It is designed for athletes and their parents, as well as for NTIS coaches and service providers. The aim of our Sports Medicine and Physiotherapy service is to not only to manage injuries, but more importantly to help try and prevent them. We see our service as playing an essential role in enhancing performance, as well as being important in giving athletes the best chance of long term sporting success. Please don t hesitate to contact the NTIS SMPC, (Tel: ), at any stage, with any questions or concerns, in relation to the content of this resource, or anything else related to NTIS Sports Medicine and Physiotherapy servicing. General Sports Medicine Principles The NTIS is responsible for: - Screening NTIS athletes for existing illness, health and musculoskeletal problems. - The development of appropriate illness and injury prevention programs. - Ensuring the provision of a referral mechanism for appropriate treatment, remedial programs and training modifications to address any identified problems. - Organising appropriate, expert and rapid intervention in the case of sport related illness or injury. - Planning and monitoring safe return to training and competition following illness or injury. Vaccination/ Immunisation An up-to-date immunisation status is strongly recommended on entering into the NTIS scholarship program. Vaccination for athletes ensures: Safe participation for athletes travelling and competing overseas Prevention of diseases which may ruin a team s competitive campaign The reduction of the risk of contracting Hepatitis B in contact sports All athletes are strongly encouraged to be up-to-date with the following immunisation/ vaccinations: 3

4 1. Tetanus 2. Polio 3. Diphtheria 4. Measles, mumps 5. Rubella 6. Hepatitis A 7. Hepatitis B 8. Typhoid 9. Chicken Pox 10. Whooping Cough 11. Meningococcus 12. Gardasil (female) Pre-participation Athlete Medical Screening In line with the National Elite Sports Council recommendations the NTIS requires all athletes to complete a comprehensive medical screening process, including an ECG, before offering any form of scholarship. It is the responsibility and intention of the NTIS not to allow athletes to enter an NTIS scholarship when it is known there is a pre-existing condition, illness or injury, that places the athlete at risk of being exacerbated or insufficiently prepared to undergo a high volume and/or high intensity training program. The NTIS require from athletes a full disclosure of training activities, injury and illnesses in completing the medical screening form and process. The NTIS will supply all athletes with the relevant medical screening forms that need to be completed. All costs incurred for pre-entrance medicals are the responsibility of the athletes. Process - All new athletes require a one off comprehensive medical screening, with a General Practitioner (GP), before being offered any form of scholarship. - Continuing athletes (i.e. those in their 2 nd, 3 rd or more years of being offered an NTIS scholarship) are not required to complete a full medical, unless otherwise indicated. Instead they must fill out and sign an annual medical disclosure form. - As of March 2012 all new and continuing NTIS athletes must also undergo a one off ECG test. Please see below for more details on what this involves. (As this is the first year of ECG testing being compulsory, there will be continuing athletes who need to get an ECG completed but not a full GP medical) Completed forms and reports must be returned to either the NTIS head coach, or directly to the NTIS Sports Medicine and Physiotherapy Coordinator. The NTIS Sports Medicine and Physiotherapy Coordinator (SMPC) may seek further clarification from the certifying doctor or request that an athlete seek further opinion from a medical specialist at the expense of the athlete. 4

5 Upon satisfactory completion of this process, athletes are cleared to be offered a scholarship agreement with the NTIS. Common Questions What is a pre-participation athlete medical screening, and why do I need one? Basically it is a series of questions and simple non-invasive medical tests designed to indicate whether you are medically and physically up to participating in an elite high level training program. What is the cost of medical screening, and who covers this cost? The cost varies between services providers, but generally it is around $110 (and there is no Medicare rebate on this consultation). The athlete is responsible for the cost of the medical screening. Where, in Darwin, can a medical screening be completed? A medical screening can be completed by any qualified GP. Most importantly the correct medical screening form needs to be completed, and so make sure you take a copy of this form with you to your appointment. There is a section that you will need to complete prior to your GP appointment. If you require an ECG as well as a medical screening, then make sure to enquire about whether these can be done at the same time. What is an ECG? An electrocardiogram (ECG) records the electrical activity of the heart. It is used to measure the rate and regularity of heartbeats as well as the size and position of the chambers and the presence of any damage to the heart. An ECG is an easy non-invasive test that generally takes between 5-10 minutes. A trained technician is required to complete the ECG, and a doctor will read and report on the results. Do I need to complete an ECG test, and why is it important? Yes, from March 2012 all NTIS athletes must undergo a one off ECG test. The National Elite Sports Council have advised that an ECG should be included as part of the routine medical screening process to help ensure athletes are safe to train and compete in a high performance sport program. If you have already had a 12-lead ECG performed as part of another sports program please contact the NTIS SMPC, (08) , to see if a further test is required. What is the cost of an ECG, and who covers this cost? Cost varies between services providers. Please see details below. The athlete is responsible for the cost of the ECG. Where, in Darwin, can an ECG be performed? Please find some options listed below: (Note: costs are a guide only and are subject to change) How do I go about organising an ECG? 5

6 Ring one of the providers listed below and explain you are an NTIS athlete requiring a pre-participation ECG. All you are required to get from the provider is the ECG trace, there is no form for them to complete (If you are willing to participate in an athlete ECG study) If not, you must get the ECG reported on (this normally incurs an extra fee). You must provide a copy of the ECG trace, and the study consent and information form (or an ECG report if not intending to be a part of the study) to the NTIS SMPC. Once your report is completed you will be given a copy of your ECG report, this normally only takes a week from submission. Please see the attached information and consent forms, on the athlete ECG study. Northlakes Medical Centre 1 Links Rd, Marrara (08) NT Cardiac Darwin Private Hospital, 105 Rocklands Dr, TIWI, (08) Territory Sports Medicine Alice Springs Family Medical Centre Mall Medical Centre Shop 8, Parap Place, Parap (08) Stuart Highway, Alice Springs (08) /73 Hartleigh St, Alice Springs, (08) ECG only = $45 (No Medicare rebate) No referral required. Ask to book in with a nurse for an NTIS ECG screening. - Pre-participation medical screening + ECG = $165 (No Medicare rebate) - ECG Only = $65 with $25 Medicare Rebate. Must be referred by GP - ECG only= $ (No Medicare rebate) No referral required - ECG only= $50 (No Medicare rebate) No referral required - Pre-participation medical screening = $99 (No Medicare rebate) Please don t hesitate to contact the NTIS Sports Medicine and Physiotherapy Coordinator on (08) with any questions or concerns in regards to any of this process. Musculoskeletal Screening Process Level 1-4 NTIS athletes will receive annual musculoskeletal screenings. Athletes, who are in a transition phase from a level 5 to a level 4 scholarship, may also receive a musculoskeletal screening at this time. The screenings are not for treatment but are performed to identify potentially preventable musculoskeletal issues, to ensure appropriate treatment and follow up of any current injuries, and where possible, to improve sporting performance. Ideally screenings will happen prior to, or within the first month of the scholarship year. Musculoskeletal screenings will take place in the NTIS Sports Medicine and Physiotherapy Coordinator s (SMPC) office, and the cost of the musculoskeletal screening is the responsibility of the NTIS. Athletes will be notified of their screening date and time by either their NTIS Coach or the SMPC. The SMPC will report on the screening outcomes and will provide the athlete, their coach and any other relevant NTIS service team members with any recommendations. The 6

7 effectiveness of these screenings relies on good communication between all parties involved in the athletes care, including most importantly the athlete themselves. Exit Screenings All Level 1-4 athletes are offered an exit screening with the SMPC prior to the end of their scholarship term. It is the athlete s responsibility to organise a time for this screening. It is not compulsory, but it is recommended as a way of evaluating any injuries that occurred during the scholarship period and examining all regions of the body for any undiagnosed conditions. If the athlete chooses not to organise, or fails to attend, this screening it is assumed that they have left the program in a fit and healthy condition, with no ongoing injury concerns as a result of their involvement with the NTIS. This screening needs to be completed within a fortnight of their scholarship ending. Sports Medicine Clinic/ Servicing The NTIS has its own Sports Medicine and Physiotherapy Coordinator (SMPC) who is an Australian registered Physiotherapist. Appointments with the NTIS SMPC are available for Level 1-4 NTIS scholarship holders on weekdays and can be organised by contacting (08) , unless otherwise notified. The higher scholarship holders receive priority for appointments with the NTIS SMPC unless intervention of a greater medical attention is required. This is the discretion of the NTIS SMPC. When the Level 1-4 NTIS scholarship holders presents to the NTIS SMPC for an injury or assessment, they will be examined and an appropriate management plan will be outlined depending upon their condition. The cost of this service is the responsibility of the NTIS. Level 5 NTIS scholarship holders may be provided with educational sessions from the NTIS SMPC periodically during the term of their scholarship to better understand and prepare them for training, competition or injury/illness. This servicing is determined by each individual sport head coach or program coordinator at the start of each scholarship year. Whilst the SMPC is not responsible for direct treatment or management of Level 5 athletes, they are able to assist, for example, in recommending appropriate external services. Athletes who are in a transition phase from a level 5 to a level 4 scholarship may receive clinical servicing from the SMPC during this phase. All NTIS athletes, Level 1 to 5, are responsible for keeping the SMPC up-to-date with any medical or injury concerns. This information is important in ensuring coaches and in-the-field-staff are aware of the injury status of all NTIS athletes within their program. Access to other Medical/ Allied Health service providers 7

8 Aside from the SMPC the NTIS does not have any other in-house medical or allied health service providers. In accordance with an athlete s injury management/ prevention plan referrals will be made to external service providers, for example to general practitioners, sports physicians, podiatrists, nutritionists, optometrist etc. Responsibility for the cost of these outsourced services, for Level 1-4 athletes, is on a case-by-case basis. (Level 5 athletes are responsible for all of their own medical costs). For more detail regarding this please refer to the NTIS Schedule of Sports Medicine Services for Reimbursement. At the discretion of the SMPC, Level 1-4 athletes may be sent for a second physiotherapy opinion, specialised assessment or treatment. The choice of the external provider is at the discretion of the SMPC, who will endeavour to use sport squad physiotherapists where practicable and where these practitioners are the experts in the desired field. In this instance the NTIS will be responsible for the cost of the external physiotherapy costs. Athletes and or/ their parent or guardian may request a second physiotherapy opinion, in this case the athlete/ parent will be responsible for any costs incurred. The SMPC will liaise directly with any external providers to ensure one clear treatment plan is being communicated to the athlete. Injury Notification Responsibilities Please see Appendix 2 for a copy of the NTIS Athlete Injury Notification Form. This form must be completed for all injuries, and must be returned to the NTIS Sports Medicine and Physiotherapy Coordinator. Athletes (of all scholarship levels) 1. Athletes must ensure immediate reporting of all injuries to their NTIS squad coach, and between the coach and athlete an NTIS Athlete Injury Notification Form completed and returned to the NTIS SMPC. 2. Athletes must ensure prompt and accurate reporting as to the time, place and mechanism of any injury. 3. Athletes must provide the NTIS SMPC and external sports medicine service providers with all relevant information in respect to the injury as required by the athlete agreement. Coach 1. Coaches must ensure the athlete seeks prompt advice and management for all injuries. 2. Coaches must ensure that the NTIS SMPC is promptly notified and kept informed of any injury and its management. An NTIS Athlete Injury Notification Form must be completed and returned to the NTIS SMPC. 3. Coaches must assist and oversee any rehabilitation programs implemented for an athlete. Sports Medicine Co-ordinator 1. The SMPC will ensure appropriate and timely communication with all relevant parties involved in the athletes injury management plan (e.g. with the athlete and their parent(s), NTIS staff, external service providers and appropriate club personnel, etc), 2. The SMPC will ensure communication is in-line with confidentiality standards as laid out in the athlete agreement, and as determined by their professional code of practice. 8

9 Injury Management by Club Personnel (Level 1-4 Athletes) If an injury occurs whilst training or competing for the athletes club the athlete should seek immediate acute management from any club medical personnel. They should report the outcomes of this management as soon as possible to the NTIS SMPC. If this injury requires any follow up treatment they must be assessed by the NTIS SMPC and an injury rehabilitation/management plan will be designed. This plan will be communicated to club personnel, who may be involved in the injury management process. It is the NTIS SMPC who overseas this process and ultimately determines the treatment plan. DARWIN REGION INJURY MANAGEMENT FLOW CHART (Level 1-4 Athletes) ATHLETE INJURY OCCCURS REPORT TO NTIS COACH & REFERRAL TO SPORTS MEDICINE & PHYSIOTHERAPY COORDINATOR (SMPC) SMPC ASSESSMENT Acute injuries seen within 24 hours Chronic injuries within 48 hours (No weekend SMPC service is available- if urgent assessment required Royal Darwin Hospital recommended) (If the SMPC is away for any reason the Athlete Services Manager, , will be the main point of contact and will be the one to refer to external services as required.) REFERRAL to other Specialists as required IDENTIFICATION OF RED FLAGS Immediate REFERRAL to Sports Physician or GP TREATMENT (If requiring Physiotherapy) INJURY RESOLUTION INJURY NOT RESOLVING with 6 treatments or within 6 weeks 9

10 Southern Region Athletes REFFERAL to Sports Physician for further investigation NTIS approved practitioners Southern region NTIS athletes are required to use nominated NTIS physiotherapists if they want to be reimbursed for medical costs. If they do not use a NTIS nominated physiotherapist no expenses will be covered. A physiotherapist may become a NTIS approved physiotherapist if they meet 2 of the 4 following criteria. 1. A Masters degree in Sports, Musculoskeletal or Manipulative therapy 2. Be an APA titled Sports or Musculoskeletal Physiotherapist 3. Has had experience working with international or national level athletes previously 4. Has greater than 5 years experience as a physiotherapist in outpatients musculoskeletal physiotherapy Southern region athletes will be notified of the names and contact details of these therapists. Medical clearance, Pre-existing injuries and exit screening procedures are the same as for Darwin based athletes. Injury management (Level 1-4 Athletes) The athlete must report any injury or condition to their NTIS squad coach, who will in turn report it to the NTIS SMPC. They will then be referred to their GP or an NTIS nominated physiotherapist for management of this condition as required. See injury management flowchart for Southern region. After each consultation the treating practitioner is required to complete an injury report and return it to the NTIS SMPC. If the condition is requiring more than 6 consultations the treating practitioner needs to complete a more detailed report to the NTIS SMPC. This report should outline the diagnosis of the condition, contributing factors, the treatment being performed, any rehabilitation requirements, the prognosis and estimated number of consultations required. Upon receiving the report it is up to the NTIS Sports Medicine and Physiotherapy Coordinator discretion as to whether further treatment is supported financially. SOUTHERN REGION INJURY MANAGEMENT FLOW CHART (Level 1-4 Athletes) ATHLETE 10

11 INJURY OCCCURS NTIS SQUAD COACH NOTIFIED (who in turn notifies Darwin based SMPC, or the Athlete Services Manager if the SMPC absent) REFERRAL TO NTIS APPROVED PRACTITIONER TREATMENT (If requiring Physiotherapy) Identification of RED FLAGS Immediate REFERRAL to Sports Physician or GP REFERRAL to other Specialists as required INJURY RESOLUTION INJURY NOT RESOLVING with 6 treatments or within 6 weeks REPORT TO SMPC FOR REVIEW Single Sport All NTIS athletes must notify NTIS coaching staff of any other sports they are participating in outside of their NTIS scholarship sport. This is important in assisting coaches to plan appropriate workloads, and in doing so enhance performance and minimise injury risk. 11

12 Any injury that occurs while participating in a sport or activity not related to their scholarship sport, and/or not sanctioned by the athlete s Head Coach is not covered under the NTIS athlete agreement. These injuries need to be managed at the athlete s own cost. Should this occur the athlete is required to: a) Notify the NTIS Sports Medicine and Physiotherapy Coordinator of the injury. b) Seek treatment from an external medical provider. c) Upon completing treatment, all athletes Level 1-5, must ensure that the NTIS Sports Medicine and Physiotherapy Coordinator has a medical clearance report from the treating practitioner regarding that injury. d) Level 1-4 athletes are required to undergo a musculoskeletal screening with the NTIS Sports Medicine and Physiotherapy Coordinator prior to returning to NTIS commitments. Reimbursement of Medical Expenses Level 1-4 athletes may be eligible for contribution towards investigation, specialist, or external servicing costs for Sports Medicine needs. Appendix 1 is a copy of the Schedule of Sports Medicine Services and it gives a basic outline of what may or may not be covered. Coverage is based on NTIS scholarship level, and many costs are considered on a case-by-case basis. All costs for reimbursement must be approved by the NTIS SMPC prior to the service/ good being sought. Process 1. Approval sought, by the athlete or program coach, for sports medicine related service provision/ good. In many cases it will be the SMPC advising the athlete of what external service/ good is required (e.g. x-ray). 2. Approval granted by the NTIS SMPC. 3. Service sought/ good purchased 4. The athlete is required to pay the full amount of the account themselves and claim any Medicare or private health insurance rebate they are entitled to. 5. The athlete must then send the receipt, along with a completed NTIS MEDICAL EXPENSE REIMBURSEMENT CLAIM FORM; and an NTG GAS (Government Accounting System) PAYMENT DETAILS INDIVIDUAL / NON BUSINESS form to the NTIS Sports Medicine and Physiotherapy Coordinator. Copies of these forms can be found as Appendix 2 and 3 6. The NTIS Sports Medicine and Physiotherapy Coordinator will then approve reimbursement for the amount allocated on the schedule of services, if the claim is eligible, and organise for direct reimbursement into the athletes nominated bank account. The NTIS is not to be billed directly for any athlete medical out-of-pocket expenses regardless of their scholarship level. 12

13 Claims for reimbursement must be submitted within 6 weeks of the service/ good being supplied in order to be eligible for reimbursement. Claims submitted outside this timeframe will not be accepted. Post Scholarship Injury Management Any injury sustained by an NTIS athlete after their scholarship term has ceased is not covered under the scholarship agreement. These injuries will need to be managed at the athlete s own cost. If an athlete has been injured during the period of their NTIS scholarship agreement, the athlete is entitled to the NTIS Sports Medicine and Physiotherapy Coordinator services, as allowed for by their scholarship agreement, until the injury has resolved. This management may therefore by necessity continue past the end of the scholarship term and in such cases an athlete scholarship extension may be sought. If an athlete is being managed for a long-term injury, continuation of treatment will be negotiated on a case-by-case basis between the NTIS and the athlete. Services agreed upon will be detailed in the schedule of the Injured Athlete Scholarship Agreement. All athletes requiring post scholarship management will be required to sign the Injured Athlete Scholarship Agreement. Athlete Education Sessions Athlete education sessions may be run throughout the year. The topics and timings of these sessions are largely determined by requests from NTIS squad coaches or program coordinators. If you have a particular topic of interest please make sure to let your NTIS coach or the SMPC know. An education booklet on Nutrition, Hydration and Recovery for elite athletes is available for all athletes on request, to either your NTIS coach or to the NTIS SMPC directly. Other useful educational websites include that of the Australian Institute of Sport and Sports Medicine Australia. Other NTIS Sports Medicine Policies The NTIS has a number of medical policies and guidelines which it adheres to. These include: - Infectious Diseases & HIV Policy 13

14 - Concussion and Head injuries Policy - Mouth Guard Recommendations - Testing and Management of Iron and Ferritin Levels in Athletes Guidelines - Anti-doping Policy - Sun and Heat Protection Guidelines Copies of these policies are available on the NTIS website, or from the SMPC, (08) Failure to comply with NTIS Sports Medicine and Physiotherapy Coordinator Recommendations Failure to comply with SMPC recommendations will result in athlete disciplinary processes being implemented. This may include failure to attend appointments without notification, failure to attend appointments with external practitioners, failure to follow treatment and management requests. Appendix 1: Schedule of Sports Medicine Services Coverage is based on your NTIS scholarship level (1-5) LEVEL 1-4 Scholarship LEVEL 5 Scholarship SCREENINGS > Pre- entrance Medical screening Athlete to Cover Athlete to Cover > - Physio (musculo-skeletal screenings) NTIS Cover Not Applicable PHYSIOTHERAPY >NTIS Physio Consultation, Regional & Interstate consultation NTIS Cover No Cover Darwin external physio consultation if not referred from NTIS NTIS Physiotherapist/ Manager Athlete Services No Cover No Cover Darwin external physio consultation if referred from NTIS NTIS Physiotherapist/ Manager Athlete Services Case by case No Cover Equipment and braces Case by case No Cover DOCTOR SERVICES GP, Sports Physician, Resident: Injury Management Gap Payment No Cover > Injections- GP Case by case No Cover 14

15 > flu shot Gap Payment No Cover SURGERY > Surgery costs May receive Gap Payment No Cover RADIOLOGY > X-rays Ultra-sound Bone & CT Scan Gap Payment No Cover > MRI Case by case No Cover PATHOLOGY Case by case No Cover PODIATRY - consultations MASSAGE- during competition ORTHOTICS Gap Payment Max $300 Prior Approval required NTIS Cover Gap Payment Competition and Training Budget No Cover No Cover No Cover DENTAL, OPTICAL, PHARMACEUTICAL, ACUPUNCTURE, CHIROPRACTIC, REMEDIAL MASSAGE, AMBULANCE No Cover unless in writing No Cover Appendix 2: NTIS Athlete Injury Notification Form Athlete Name: Contact No: Sport and Recreation Northern Territory Institute of Sport 1st Floor, Arafura Stadium, 40 Abala Rd, Marrara Postal address PO Box CASUARINA NT 0811 Tel Fax Sport: NTIS Coach: Injury: Date of Injury: New / Recurrent Injury 15

16 Injury Nature & Mechanism - (What is it/ what does it feel like & specifically how did it happen?) Where did the injury occur? Was it during an NTIS training session or game? Y / N What was the management at the time of injury, and how has it been managed to date? (i.e. ice, rest, saw physio, referral to hospital etc) Are you/ is the athlete being followed up by an external health professional? Y / N If yes who: Dr / Physio / Other: Clinic Name: Their Name: Contact Details: Do you/ does the athlete need any ongoing management/ treatment in order to safely participate in the NTIS program? Y / N If No, please detail why and a return to sport plan (i.e. injury fully resolved): If Yes, why and what is it that you feel you need? Is the athlete continuing to train and or play in their present condition? Train Y / N Play Y / N Training/ playing modifications/ limitations: Do you/ does the athlete require follow up from the NTIS Sports Medicine Coordinator? Y / N Form completed by: Date: Contact Details: NTIS Sports Med Coordinator to complete: Injury notification received- Date: Follow-up required Injury episode closed- Date Relevant stakeholders advised of outcomes 16

17 Appendix 3: NTIS MEDICAL EXPENSE REIMBURSEMENT CLAIM FORM NAME: EXPENSES FOR PERIOD: / / TO / / DATE Expenditure Injury TOTAL BILL MEDICARE REBATE HEALTH INSURANCE REBATE AMOUNT FOR NTIS REIMBURSEMENT E.g. Physiotherapy Right hamstring $ $ $ $ TOTALS $ $ $ $ $ $ $ $ $ $ OFFICE USE ONLY PLEASE ATTACH ALL RECEIPTS, INCLUDING A TAX INVOICE AND MEDICARE AND HEALTH INSURANCE STATEMENTS AS APPLICABLE PLEASE RETURN COMPLETED FORM TO SPORTS MEDICINE AND PHYSIOTHERAPY COORDINATOR PLEASE NOTE REIMBURSEMENT MAY TAKE UP TO 1 MONTH OF THIS FORM BEING PROCESSED I DECLARE THAT THE ABOVE INFORMATION IS TRUE & CORRECT, & THAT EXPENSES CLAIMED FOR ARE ONLY THOSE WHICH RELATE DIRECTLY TO MY NTIS SCHOLARSHIP Reimbursement Payment Details: Payment can only be made to over 18's. PRINT NAME: DATE: / / SIGN: If NT Government Employee, please provide your AGS no. (Reimbursement will be made directly into your NTG pay account) 17

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19 Appendix 4: NTG GAS (Government Accounting System) PAYMENT DETAILS INDIVIDUAL / NON BUSINESS AGENCY AUTHORISING PAYMENT CONTACT DETAILS: Department/Unit: Northern Territory Institute of Sport Name: Phone: Fax: INDIVIDUAL TO COMPLETE: Please print clearly Mr Mrs Miss Ms Dr NTG Employee AGS (for NTG Employees only) Last Name: Given Names: Postal Address: (Home/Residential) Suburb/City: State: Postcode: Telephone No: Fax No: Mobile No: Address: ELECTRONIC FUND TRANSFERS The Northern Territory Government s preferred method of payment is Electronic Funds Transfer. This results in an efficient and timely payment to suppliers. To enable transactions to proceed in this manner please complete the following: I authorise use of my PIPS Bank Details for GAS Payments (NTG Employees Only) Bank/Credit Society Details Name of Financial Institution: Bank account in the name/s of: BSB number (branch number): Account number: INDIVIDUALS AUTHORISATION Privacy The Department of Business and Employment (DBE) assists Northern Territory Government (NTG) Agencies in managing their tax and accounting needs. Information on this form is collected on behalf of NTG Agencies and maintained by DBE who use the information to create a Payment Record. A Payment Record is required before payment can be made using the Government Accounting System. NTG staff working in the accounting and purchasing areas of Government, the Australian Taxation Office, and the NTG s auditors have access to Payment Records. You may request access to your Payment Record by contacting DBE Accounting Services on (08) or (08) To be signed by Individual, NOT authorising Agency 19

20 I am authorised to complete this form and the details specified in this document apply to any supply provided to the Northern Territory Government. Signature: Date: Name: Position: NT GOVERNMENT USE ONLY Authorising Agency Checklist Please ensure the following items are attached to this form: With the above paperwork, forward to: Vendor Maintenance Request Form Vendor & Compliancy Group Accounting Services Additional Supporting Documentation Department of Business and Employment Ph: (08) or (08) PO Box 1900, PALMERSTON NT 0831 Fax: (08)