Forms

Stoma Appliance Scheme Forms

Page last updated: 10 February 2017

Important information regarding the forms on this page


Treating medical practitioners and stomal therapy nurses (STNs) should complete the Stoma Appliance Scheme Application Form – Department of Human Services (DHS) - Medicare Form 4031 – for their patients. This form is available from the Department of Human Services website.

Please open these files in the Internet Explorer browser to complete. If you are unable to access Internet Explorer, please download them to your computer to complete. If you need further assistance accessing the forms please email the Stoma Secretariat.

Please note these forms require handwritten signatures and therefore are intended to be paper based. The Department has made every effort to adhere to WCAG 2.0 accessibility requirements.

For Consumers

Stoma Appliance Scheme Application and Application for Additional Stoma Supplies

Irrigation Kit Authorization Form

Tieman Tip Catheters Authorization Form

For Product Suppliers

Applications to list stoma related products on the Stoma Appliance Scheme

Application to list stoma related products on the Stoma Appliance Scheme – Benchmark Groups 1-7 (PDF 435 KB)
Application to list stoma related products on the Stoma Appliance Scheme – Price Premium and Groups 8-11 (PDF 435 KB)

Application to amend or delete listing on the Stoma Appliance Scheme

Application to amend or delete listing on the Stoma Appliance Scheme (PDF 1346 KB)