General Practitioner Referral Form
Closing the Gap – Care Coordination and Supplementary Services (CCSS) Program
     
Please fax completed form to (07) 4927 2977 or email referrals@ourphn.org.au
Program Eligibility:
Is this patient currently  registered in the Indigenous Health Incentive | <Is patient currently registered in the IHI?>
This patient has completed a health assessment  (MBS 715) in the last 9-12 mths | <Has the patient completed a 715 in the last 9-12 mths?> | Is a copy of the completed health assessment attached? | <Copy of health assessment attached?>
This patient has a current GP Management Plan and/or Team Care Arrangement | <Patient has a current GPMP and or TCA?> | Is a copy of the completed GPMP / TCA attached? | <Copy of GPMP/TCA attached?>
The patient’s chronic disease type/s (tick one or more as appropriate) | <Patient chronic disease type/s - select multiple>

Reason for Referral (tick one or more as appropriate)
(Please attach any relevant letters or referrals)

•	Care Coordination Assistance (chronic disease management)
•	Supplementary Services Assistance (financial support for                             medical items below)
•	Allied Health - Identify Discipline:
•	Specialist - Identify Discipline:
•	Transport / Accomodation
•	Medical Aids: Dose Administration Aids / Assistive Breathing                        equipment  (spacers, Nebulisers) / Continuous Positive Airways                   Pressure (CPAP) Machine / Accessories for CPAP Machine /                       Blood Sugar - Glucose Monitoring    Equipment / Medical                              Footwear (prescribed and fitted by Podiatrist) / Other

Referral date: | <TodaysDate>
Referring GP details:
Name: <DrName> | Provider Number: <DrProviderNo>
Practice name | <Practice>
Source of referral | <Source of referral?>
Patient details:
Surname: <PtSurname> | First Name: <PtFirstName> | Date of Birth: <PtDoB> | Gender: <PtSex>
Does this patient Identify as: | <Does This patient identify as:> | Medicare Number:<PtMCNo>    Expiry Date: <PtMCExpiry>

Address:

<PtStreet>
<PtCity>	Postcode:<PtPostcode>

Phone number | Home: <PtPhoneH> | Work: <PtPhoneWk> | Mobile: <PtPhoneMob>

Reason my patient requires Care Coordination services (tick one or more as appropriate)

•	is at significant risk of experiencing otherwise avoidable (lenghty and/or frequent) hospital admissions
•	is at risk of inappropriate use of services, such as hospital emergency presentations
•	is not using community based services appropriately
•	needs help to overcome barriers to access services
•	requires more intensive care coordination than currently able to be provided by general                                          practice/Indigenous health staff
•	is unable to manage a mix of multiple community based services

Reason my patient requires Supplementary Services i.e. medical specialist/allied health, transport/accommodation, medical aids in accordance with care plan (tick one or more as appropriate)

•	to address risk factors, such as waiting period for a service longer than is clinically appropriate
•	to reduce the likelihood of a hospital admission
•	to reduce the patient's lenght of stay in hospital
•	not available through other funding sources
•	to ensure access to a clinical service that would not be accessible because of the cost of a local                             transport service
•	medical aid item

Patient Information and Consent:

My GP has discussed the CCSS Program Fact Sheet with me. I understand what I have been told, any questions I had about the Program have been satisfactorily answered and I want to participate. 
•	I understand that my participation is voluntary and that I have the right to withdraw from the Program at any time.
•	I understand that a range of health and community service providers may collect, use and disclose my relevant personal information as part of my care.
•	I understand that statistical information (that will not identify me) will be collected and used to see how well the program is working and help improve services for Aboriginal and Torres Strait Islander people.
•	I understand that the personal information collected by these organisations will be maintained consistent with National Privacy Principles. It will remain confidential except when it is a legal requirement to disclose information; or where failure to disclose information would place me or another person at risk; or when my written consent has been obtained to release the information to a third party.

Patient Name | <PtFullName> | Referral GP Name | <DrName>
Patient signature | | Referring GP Signature: |
Date | <TodaysDate> | Date | <TodaysDate>

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