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The Queensland Government is in a caretaker period until after the state election. Minimal updates will be made to this site until after the election results are declared.

Accommodation confirmation (Form D)

Accommodation confirmation (Form D)

Accommodation confirmation (Form D)

Section A - Patient details

(HHS to complete)

Section B - Accommodation details

(HHS or accommodation provider to complete)

Accommodation type
(if commercial accommodation)
Did the patient and / or escort stay a different number of nights than were approved?
I declare that the number of nights claimed are a true reflection of the actual nights stayed by the approved patient and / or patient escort(s)
Date * (DD / MM / YY)
Section C - Approved patient / patient escort details

(HHS to complete)

patient details
Check-in date * (DD / MM / YY)
Check-out date * (DD / MM / YY)
patient escort details
Check-in date * (DD / MM / YY)
Check-out date * (DD/MM/YY)
Section D - Approving hospital details

(HHS to complete)

Section E - Patient declaration

(patient / guardian / patient escort to complete)

I confirm that I stayed in the accommodation over the period approve above. I agree for any accommodation subsidy for which I have been approved to be paid directly to the accommodation facility. I am aware that I am liable at checkout for the full cost of any additional accommodation not previously approved by my closest public hospital or health facility.

Date * (DD/MM/YY)
Date * (DD/MM/YY)
Hospital and Health Service use only

I, as the medical superintendent (or representative), authorise the above accommodation as required.

Date * (DD / MM / YY)