30 Apr 2024

ABN 99 086 014 968

1320022111112111112220333333333333333333333333333333313030210020013 Locked Bag 14060
/000791 Melbourne City Mail Centre
M s Leanne Cheer Victoria 8001
8 Coulter St Telephone 133 466
ELIZABETH PARK SA 5113
energyaustralia.com.au

Service address: 8 COU LTER ST ELIZABETH PARK SA 5113

Account num ber: 9602902872

W e ’v e te m p o ra rily re g is te re d life s u p p o rt o n y o u r a c c o u n t

H ello Leanne

Thanks for letting us know that you or som eone at your hom e or business prem ises depends on life support equipm ent. You are
now tem porarily registered for life support on your account.

W h a t y o u n e e d to d o
To ensure your account rem ains registered for life support w ith us and your distributor, SA Pow er Netw orks (the com pany
responsible for the poles, w ires and gas pipes in your area), please com plete the enclosed M edical Confirm ation form and return
it by 31 July 2024 either by:
∑ E m a il - lifesupport@ energyaustralia.com .au
∑ M a il - EnergyAustralia Custom er Care
Locked Bag 14060
M elbourne City M ail Centre Vic 8001
L712023361900001 / E-791 S-3147 I-3147

(No stam p required)

D o y o u h a v e a c o m p le te d a n d sig n e d M e d ic a l C o n firm a tio n fo rm th a t is le ss th a n 4 y e a rs o ld ?

If you have a legible copy of your signed form that is less than 4 years old you can send it to us. Otherw ise, if you've provided this
form to your previous energy retailer or netw ork distributor in the past 4 years and don’t have a copy, you can ask them for it.
You w ill then need to send this copy to us by em ail or m ail using the details above.

C o lle c tin g y o u r p e rso n a l in fo rm a tio n

W e’ll collect personal inform ation about you and m ay collect personal inform ation about another person in your household or
business prem ises via the M edical Confirm ation form for the purpose of registering life support to your account, and for
secondary purposes w here perm itted by the Privacy Act 1988 (Cth) and the Health Records Act 2001 (Vic). If you’re not the person
requiring life support equipm ent and are providing us w ith the personal inform ation of som ebody else, please ensure that you
have the consent of that person to provide their personal inform ation to us. W e’ll disclose your personal inform ation (including
health inform ation) to your distributor and field vendors as part of m anaging your life support registration. W e’re authorised to
collect this inform ation under the National Energy Retail Law Act 2011 (SA). If you do not provide us w ith this inform ation, w e
m ay deregister your prem ises as requiring life support equipm ent and pow er to your prem ises m ay be disconnected.

You have the right to access your personal inform ation (subject to certain exceptions). Our privacy policy is available at
e n e rg y a u stra lia .c o m .a u /p riv a c y . This privacy policy contains our contact details, inform ation about how w e collect, store, use
Cont. overleaf

EnergyAustralia Pty Ltd ABN 99 086 014 968 LSTEMPREGEA

 and disclose your personal inform ation, and your rights to request access to your personal inform ation or m ake a com plaint
about our inform ation handling process.

W h a t h a p p e n s if I d o n ’t c o m p le te a n d re tu rn th e M e d ic a l C o n firm a tio n fo rm ?
Your account w ill rem ain tem porarily registered until w e receive a com pleted M edical Confirm ation form w hich has been
certified by a m edical practitioner. If you don’t provide us a com pleted form , w e m ay de-register life support from your account.
This w ould result in you not receiving protections that apply to custom ers registered for life support.

W h a t e lse y o u n e e d to k n o w
It is im portant to note that there m ay be planned interruptions to your supply (e.g. w e need to interrupt supply for m etering
purposes or your distributor SA Pow er Netw orks needs to interrupt supply for m aintenance purposes). If this w ere to occur, w e
or your distributor SA Pow er Netw orks are required to provide you advanced notification of the interruption.

In the event of an unplanned interruption you can contact your distributor SA Pow er Netw orks on 131 366, or us on 133 466.

P la n n in g a h e a d w ill h e lp
You should also ensure you have a plan in the event of any unplanned interruption to your pow er supply, including if your life
support equipm ent unexpectedly stops w orking. In your plan, w e recom m end you:
∑ Regularly check the back-up battery of your life support equipm ent so it's fully charged and ready for use at all tim es.
∑ H ave access to a telephone that doesn't require pow er to operate and a battery-operated radio to keep up to date w ith
restoration of pow er supply during severe w eather events.
∑ M ake sure you have im portant inform ation such as nam es, addresses and telephone num bers of your doctor, the
nearest hospital and fam ily and friends w ho can help you.
∑ Consider m aking an em ergency plan w ith your doctor for extended outages and em ergencies.

Please note if you ever change energy retailers, you m ust advise your new retailer that you depend on life support equipm ent in
your hom e.

A n y q u e stio n s?
A list of eligible life support equipm ent can be found on the back page of this letter.
For m ore inform ation on life support visit e n e rg y a u stra lia .c o m .a u /life su p p o rt or contact us and w e’ll be happy to help.
∑ Chat w ith us online at e n e rg y a u stra lia .c o m .a u /liv e c h a t (M onday to Friday, 8.00am -9.00pm & Saturdays,
9.00am -6.00pm ) or
L712023361900001 / E-791 S-3148 I-3148

∑ Em ail us at life su p p o rt@ e n e rg y a u stra lia .c o m .a u or

∑ Call 1 3 3 4 6 6 (M onday to Friday, 8.00am -8.00pm )

If y o u n e e d a n in te rp re te r to h e lp y o u , p le a s e c a ll 1 3 0 0 6 2 2 7 1 8

Regards,

Lisa M avrodis
H ead of Operations

EnergyAustralia Pty Ltd ABN 99 086 014 968

 W h a t is life su p p o rt e q u ip m e n t?
Any of the follow ing equipm ent fall w ithin the definition of life support equipm ent:
∑ oxygen concentrator
∑ interm ittent peritoneal dialysis m achine
∑ kidney dialysis m achine
∑ chronic positive airw ays pressure respirator
∑ Crigler Najjar syndrom e phototherapy equipm ent
∑ ventilator for life support
Any other equipm ent that a m edical practitioner certifies is required for life support, this m ay include but is not lim ited to:
∑ external heart pum p
∑ respirator (iron lung)
∑ suction pum p (respiratory or gastric)
∑ feeding pum p (kangaroo pum p, or total parenteral nutrition)
∑ insulin pum p
∑ airbed vibrator
∑ hot w ater
∑ nebuliser, hum idifier or vaporiser
∑ apnoea m onitor
∑ m edically required heating and air conditioning
∑ m edically required refrigeration
∑ pow ered w heelchair
L712023361900001 / E-791 S-3149 I-3149

EnergyAustralia Pty Ltd ABN 99 086 014 968

 Medical Confirmation Form
D a te o f issu e : 30 Apr 2024

Use this form to provide medical confirmation and ensure your account remains registered for life support with us and your distributor.
We will disclose your personal information (including health information) to your distributor and field vendors as part of managing
your life support registration. If you don’t provide us with the information in this form we may deregister your premises as requiring life
support equipment and power to your premises may be disconnected (which may affect the operation of the equipment).

You must send your completed form to us by If you have any questions or want to request more time to
3 1 -0 7 -2 0 2 4 complete and return your form, please contact us and we’ll be
Email: lifesupport@energyaustralia.com.au happy to help.
Fax: (03) 9060 0007 • Chat with us online at energyaustralia.com.au/livechat
Mail: EnergyAustralia Customer Care (Monday to Friday, 8am-9pm & Saturdays, 9am-6pm AEST)
Locked Bag 14060 • Email us at lifesupport@energyaustralia.com.au
Melbourne City Mail Centre Vic 8001 • Call 133 466 (Monday to Friday, 8am–8pm AEST).

I have life support equipment in my premises and I wish to have the residence registered as life support dependent at this
address. I agree to inform EnergyAustralia if the person for whom the life support equipment is required vacates the premises or
no longer requires the life support equipment.

I acknowledge these conditions and certify any information given below is true and correct.

I consent to EnergyAustralia collecting, using and disclosing the personal information contained in this form
(including health information) to ensure that life support requirements at my premises remain registered
with EnergyAustralia and my distributor. If personal information of another person included in this form, I
confirm that I have the consent of that person, or are otherwise authorised, to provide that information to
EnergyAustralia and permit EnergyAustralia to use and disclose that information.

Returning your completed form will satisfy your requirement to provide medical confirmation under the relevant rules and
regulations and maintain life support registration at your premises. Please note, if you are a NSW or Victorian resident you may
be eligible for any applicable state government life support rebates or concessions. To ensure you receive any eligible rebates or
concessions, you need to complete the relevant state government application form.

1. Details
L712023361900001 / E-791 S-3150 I-3150

Title First name Surname

Energy supply required for life support equipment Electricity Gas Electricity and gas

Electricity account number Gas account number

Service address where equipment is located

Street number Street name

Suburb State Postcode

NMI/MIRN number on bill (if known)

Telephone Work/mobile telephone

Date you require energy supply for the purposes of life support equipment:

Cont. overleaf
 2. Life Support Equipment

I, or a member of my household, make use of the following life support equipment:

Chronic positive airways

Phototherapy equipment Oxygen concentrator
pressure respirator/devices
Chronic positive airways pressure Intermittent peritoneal Crigler Najjar syndrome
respirator/devices (24 hr) dialysis machine phototherapy equipment
External heart Kidney dialysis Enteral feeding
pump machine pump
Ventilator for Total Parenteral Nutrition
life support (TPN) pump
Other equipment fuelled by electricity or gas,
certified by a medical practitioner (please detail):

3. Medical practitioner confirmation

I, (Doctor)

hereby certify that a person residing at the above address requires the life support equipment
indicated above.
Provider Number: Name of medical practice/hospital where Phone number of medical
patient was reviewed: practice/hospital:

Signature and stamp of

medical practitioner: Date:

4. Customer’s confirmation

I,
L712023361900001 / E-791 S-3151 I-3151

certify that the details given above are true and correct and declare that I am responsible for the accounts at the service
address where life support equipment is installed.

Signature of customer: Date:

We’ll collect personal information about you as the account holder and, if applicable, another person at the premises who requires life support equipment, via this
Medical Confirmation Form and applicable life support concession forms. This information is collected for the purpose of registering life support requirements
to the account, as set out in our privacy policy or where permitted by applicable privacy laws. If you’re not the person requiring life support equipment and are
providing us with the personal information of somebody else, please ensure that you have the consent of that person, or are otherwise authorised to, provide their
personal information to us. We may disclose this personal information (including health information) to your distributor and, in some cases, field vendors as part
of managing your life support registration. We’re authorised to collect this information under the energy laws. If you do not provide us with this information and
the information is required to obtain a government concession, we will not be able to process your application for that concession. Also, where the information
is required to register that someone at your premises uses life support equipment, we do not have to register your premises, and power to your premises may
be disconnected by your distributor (which may affect the operation of that equipment). You have the right to access your personal information in accordance
with the Privacy Act. Our privacy policy is available at energyaustralia.com.au/privacy. This privacy policy contains our contact details, information about how
we collect, store, use and disclose your personal information, and your rights to request access to your personal information or make a complaint about our
information handling processes.

EnergyAustralia Pty Ltd

ABN 99 086 014 968
Locked Bag 14060, Melbourne, Vic. 8001
energyaustralia.com.au