General Practitioner Referral Form
Closing the Gap – ITC (Integrated Team Care) Program
     
Please fax completed form to (07) 4131 0899
 OR 
send via Medical Objects to - ITC, BUNDABERG (BI4670000YJ)

Patient Details:
Re: <PtFullName>  
Surname: <PtSurname>   Firstname: <PtFirstName>
DOB: <PtDoB>   Gender <PtSex>
Patient identifies as: <Patient identifies as>
Medicare number: <PtMCNo> Ref: <PtMCLine>  Expiry Date: <PtMCExpiry>
Health Care Card Number: 
DVA Card Type & Number: <PtDVACard>   <PtDVANo>
Residential Address:  <PtAddress>
Postal Address: <PtPOAddress>
Home Phone: <PtPhoneH>   Work Phone: <PtPhoneWk> Mobile: <PtPhoneMob>

Program Eligibility:
Is this patient currently registered in the Indigenous Health Incentive? <Is patient registered in Indigenous Health Incentive? (must register to be eligible)>
Has the patient completed a health assessment  (MBS 715) in the last 9-12 mths? <Has the patient completed a 715 in the last 9-12 mths? (needs to be completed to be eligible)>
Is a copy of the 715 Health Assessment attached? <Is a copy of the 715 health assessment attached?>
Date of Assessment: <Date of assessment?>  
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? <Is a copy of the completed GPMP / TCA attached?>
Patient's Chronic Disease Type/s: <Patient chronic disease type/s - select multiple>      
Other (please specify): <Other Chronic Disease (specify)> 

Reason for Referral:
Referral to Specialist: <Reason for Referral - Referral to Specialist?> (Please attach copies of Referrals to Specialist as required)
Discipline and/or name of Specialist: <Identify discipline and / or name of specialist>
Medical Aids required: <Aid/s and/or appliances requested-can select more than one>
Please list aids or applicances if not listed above: <List aids or appliances not listed above>

Referral Details:
Referral Date: <TodaysDate>
Referring GP and Provider Number:  <DrName>  <DrProviderNo>
Practice Name: <Practice>
Practice Contact: <Name of nurse at practice to contact for ITC questions>

Reason patient requires Care Coordination Services: <Reason patient requires Care Coordination Services>
Reason patient requires Supplementary Services: <Reason patient requires Supplementary Services>

Can we provide your Client with a copy of the GPMP and 715 Health Assessment? <Can we Provide  your Client with a copy of the GPMP and 715>

Patient Information and Consent:
My GP has discussed the ITC Program and referral process with me. I understand what I have been told, any questions I had about the Program have been satisfactorily answered and I wish 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/or 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.
•	I understand that it is my responsibility to ensure that any medical aids supplied to me are kept clean and well maintained according to manufacturer's recommendations to ensure efficient operation. 
•	I will attend any follow up appointments as part of the monitoring and treatment plan regarding the use and effectiveness of the medical aid as requested by the Care Coordinator or Provider.
•	I understand that the PHN may process a Medicare claim  for any Specialist service I may receive.
•	I understand that I am obliged to attend all scheduled appointments and that non-attendance will result in being responsible for any associated fees and will result in withdrawal of ITC support

Does the patient consent to the above?:  

Referring GP: <DrName>
Date: <TodaysDate>

If you require further information regarding the ITC program please contact:
			
Care Coordinator
Bundaberg
Ph: 07 4131 0800

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Past history list (selected)
<SelectedPMH>

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Investigation reports
<Ix>