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: <<Patient Demographics:Full Name>>
Surname: <<Patient Demographics:Surname>>   Firstname: <<Patient Demographics:First Name>>
DOB: <<Patient Demographics:DOB>>
Patient identifies as: <<Patient identifies as>>
Medicare number: <<Patient Demographics:Medicare Number>> Expiry: <<Patient Demographics:Medicare Expiry Date>>
Health Care Card number: 
DVA number: <<Patient Demographics:DVA Number>>
Residential address: <<Patient Demographics:Full Address>>
Postal address: <<Patient Demographics:Full Address Postal>>
Home phone: <<Patient Demographics:Phone (Home)>> Work phone: <<Patient Demographics:Phone (Work)>> Mobile: <<Patient Demographics:Phone (Mobile)>>

Program eligibility:
Patient currently registered in the Indigenous Health Incentive? (must register to be eligible) <<Registered in the Indigenous Health Incentive?>>
Has the patient completed a Health Assessment (MBS 715) in the last 9-12 mths? (needs to be completed to be eligible) <<Health Assessment (715) in the last 9-12 mnths?>>
Is a copy of the 715 Health Assessment attached? <<Copy of the 715 Health Assessment attached?>>
Date of Assessment: <<Date of Assessment?>>
The patient has a current GP Management Plan and/or Team Care Arrangement? <<Patient has 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's chronic disease type/s (please list)>>

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 (please list)>>

Referral details:
Referral date: <<Referral date>>
Referring GP & provider number: <<Doctor:Name>>   <<Doctor:Provider Number>>
Practice name: <<Practice:Name>>
Practice contact: <<Name of practice nurse to contact re: ITC>>

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 patient with a copy of the GPMP and 715? <<Can we provide patient a copy of 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: <<Doctor:Name>>
Date: <<Miscellaneous:Date (short)>>

If you require further information regarding the ITC program please contact:

Care Coordinator
Bundaberg
Ph: 07 4131 0800

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Investigation results (selected)
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Progress notes (selected)
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