The following Prosthetic Limb Services (PLS) forms and clinical criteria are available for general use:

Forms

• Discretionary Form - Upper & Lower Limb Form (PDF)
• Interim Prosthesis Form (MS Word)
• Minor Repair Voucher (PDF)
• Outcome Review Form - Knee (PDF)
• Outcome Review Form - Combined (PDF)
• Primary Prosthesis Form (MS Word)
• Replacement or Major Repair Form (MS Word)
• Prosthesis Evaluation Form (PDF)

Clinical Criteria

• Titanium Prosthetic Components PPG (PDF)
• Bariatric PPG (PDF)
• Roll-on Liners Clinical Criteria (PDF)

Accreditation Guidelines

• PLS Accreditation Guidelines (PDF)
• PLS Prescriber Eligibility Form (MS Word)

Funding Guidelines

• Funding Guidelines for the Prosthetic Limb Service (PDF)

Components List

EnableNSW funds a wide range of prosthetic components for use in prosthetic limbs. For more information about components on the list and whether they are suitable for you, we recommend that you speak with your Prosthetic Service Provider.

• Information sheet Contract 980B Prosthetic Components