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Page 1 of 5 Continuing the Mission of the Sisters of the Little Company of Mary
All about the Mary Potter Foundation In 1994 under the auspices and assistance of the Sisters of the Little Company of Mary, Calvary Health care Tasmania established a service to provide a unique healthcare service for those in need of hospital care who many not be able to access the facilities of Calvary Health Care Tasmania for reasons of economic hardship.
Mary Potter
The tradition of the Sisters of the Little Company of Mary dates back to 1877, in Nottingham, England.
It was then, in a remodelled factory, that an English woman of vision, Mary Potter, and a few followers began to pray and care for the sick, poor, unwanted and dying.
Mary Potter and her early companions ministered to the needy in the spirit of Mary, mother of Jesus. That small company of faithful followers was the beginning of today’s order of the Sisters of the Little Company of Mary.
Calvary Health Care Tasmania is a Catholic, not-for-profit private hospital network with over 400 beds providing acute and sub-acute services to the people of Tasmania. Spread across four hospitals covering both Northern and Southern Tasmania and with close to 1500 employees, Calvary Tasmania is part of the Little Company of Mary Health Care, a national Catholic and aged care service provider.
Establishment
The Mary Potter Foundation was established through an initial grant of $50,000 from Calvary Health Care Tasmania and from generous individual donations from the wider Tasmanian community.
The Need
Tasmanians, similar to Australians in other states, are experiencing increased hardship. With an ageing population, the demands on medical resources and healthcare in Tasmania, Calvary Health Care has initiated this program for those in need.
Commitment
Calvary Health Care Tasmania was established in 1938 and takes pride in its distinguished reputation of serving the Tasmanian Community. This reputation is founded on providing high quality clinical services in a caring and compassionate environment.
Administration
Referral to the Foundation is open to Calvary Health Care Tasmania’s accredited medical practitioners, who are required to ensure those patients referred meet the necessary guidelines. The administrators of the Foundation (Calvary Community Council) will be guided by the recommendations of these medical practitioners.
Updated August 2019 Uncontrolled when printed
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Criteria for Assistance
Whilst administrators of the Foundation will always reserve the right to assist a person they believe to be ‘disadvantaged’, nevertheless, in ordinary circumstances, an applicant seeking financial from the Foundation must meet the criteria as set out in the application form.
Application form is on following pages...
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Page 3 of 5 Continuing the Mission of the Sisters of the Little Company of Mary
Mary Potter Foundation Application CALVARY TASMANIA
APPLICATION FOR MEDICAL ASSISTANCE - Criteria
1. The Mary Potter Foundation is administered by the Calvary Community Council (CCC) which assesses all applications
2. Applications to the Mary Potter Foundation are made by accredited Medical Practitioners who recommend treatment or a procedure forthose experiencing economic hardship. For the purposes of this application process, the CCC considers the accredited MedicalPractitioner as the applicant
3. The Mary Potter Foundation considers applications where a patient lacks capacity to pay due to some form of disadvantage or impairedsocial-economic circumstances acknowledged by the practitioner. It invites patients to make a contribution to payment where possible
4. If the patient does not have private health insurance the Calvary Community Council considers full or part payment of Calvary hospitalcharges
5. If the patient does have some level of private health insurance the Calvary Community Council considers full or part payment of Calvaryhospital charges above what is paid by the patient’s private health insurance
6. It is the responsibility of the applying Medical Practitioner to ensure other medical practitioners involved in the care of the patient agreeto charge Medicare rates only
7. The Council approves requests for funding from a limited resource and for this reason is unable to fund the cost of prostheses.
8. If prostheses are required the applicant is encouraged to negotiate arrangements with suppliers
For further information on the Mary Potter Foundation, please see section ‘All about the Mary Potter Foundation’ at the beginning of this document
PLEASE COMPLETE THIS APPLICATION ELECTRONICALLY, SAVE as PDF and SUBMIT TO ADDRESS AT THE END OF THE FORM.
HAND WRITTEN SUBMISSIONS WILL NOT BE ACCEPTED
Patient Details
Title (Mr, Mrs, Miss, Ms etc.) Given Names
Surname DOB
Address:
Suburb State Postcode
Best Contact Phone Number(s)
Medicare Card Number Ref #
If applicable please answer the following:
Health Care Card Number
Pension Card Number
Private Health Provider Membership #
OFFICE USE ONLY: Application Reference :
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Page 4 of 5 Continuing the Mission of the Sisters of the Little Company of Mary
OFFICE USE ONLY: Application Reference :
Referring Medical Practitioner’s Details (Must be accredited with Calvary Health Care Tasmania)
Title (Dr, Mr) Surname
Given Names Field of Specialty
Practice Address:
Suburb State Postcode
Information
The Administrators of the Mary Potter Foundation will assess this application on the responses to the questions below and any additional relevant information provided with the application. Please invite the patient to make some contribution to their costs where possible. The patient requires assistance because of the following circumstances (detailed in questions 1-9):
1: Please (in detail) list the relevant reasons for this application to be supported:
(Outline details of any financial, social, physical, disability or other hardships)
2. Has the medical condition resulted from a work related accident, disease or traffic accident?
[ ] YES [ ] NO
3. Has a claim for damages, MAIB benefits or workers compensations benefits been made in relation tothe medical condition?
[ ] YES [ ] NO
4. If yes, what is the reason why money from that source is not available to cover the costs of theprocedure?
5. Proposed procedures and treatment details that will be undertaken at Calvary Tasmania:
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6. Relevant Item Numbers:
7. Expected length of stay in days:
8. Will any CCU stay be required following surgery?
[ ] YES [ ] NO
We will obtain quotes for the procedures based on your answers to questions 5 - 8, there is no need to supply us with quotations.
9. Is there any further Information that you wish to supply regarding this patient, in addition to theabove questions and information? Supporting documentation can also be attached to theapplication should it be required:
Agreement:
I request consideration of this patient for treatment via assistance from the Mary Potter Foundation.
I confirm this patient meets the criteria for assistance.
I (and any other medical colleagues involved) will treat the patient for the Medicare reimbursement only.
Signature of Practitioner: (Print & Sign) or Type Name below Acknowledging above
Date:
Submission:
This form is to be completed by a Medical Practitioner who is currently accredited with Calvary Health Care Tasmania.
Please complete electronically, using this form - Hand completed forms will not be accepted After completion Save this form as a PDF and forward the application form via Email to: [email protected]
OFFICE USE ONLY: Executive Comment if applicable:
Updated August 2019 Uncontrolled when printed
