General Practitioner Referral Form
Closing the Gap – ITC (Integrated Team Care) Program
     
Please fax completed form to (07) 4161 1225

Program Eligibility: 	
Is this patient currently  registered in the Indigenous Health Incentive 	 <Is patient registered in IHI? Must register to be eligible.>
	
This patient has completed a health assessment  (MBS 715) in the last 9-12 mths
(Needs to be completed to be eligible)	 <Has the patient completed a 715 in the last 9-12 mths?>	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?>	 
	
The patient’s chronic disease type/s 

Please list Chronic disease type if not listed above	  <Patient chronic disease type/s - select muiltiple>                                                                                                                                                             
    <Please list chronic disease type if not listed above> 	
Reason for Referral
(Please attach copies of Referrals to Specialist as required)

Medical aids required

Please list aid/s or appliance requested if not listed above
	<Referral to:>
<Identify discipline and / or name of specialist>

<Aid/s and/or appliances requested-can select more than one>

<List aids or appliances not listed above>
	
Referral date:	 <Date of Referral to ITC Program>	
Referring GP and Provider Number: 	<Name of Referring GP>  
Provider Number: <Provider number of referring GP>	
Practice name 	<Practice>	
Practice contact	<Name of nurse at practice to contact for ITC questions>	
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>
Health Care Card Number: <Health Care Card number?> 
Pension number: <PtPensionNo> 
DVA Card Type & No: <PtDVANo> <PtDVACard> 	
Address:
               	 Residential : <PtAddress>	

Postal : <PtPOAddress>		

Phone number	Home:    <PtPhoneH>                	Work: <PtPhoneWk>	Mobile: <PtPhoneMob>	
Reason my patient requires Care Coordination services 	<Reason patient requires Care Coordination Services>	
Reason my patient requires Supplementary Services	<Reason patient requires Supplementary Services>	
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 Bluecare 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	
Patient Name	<PtFullName>	Referral GP Name	<DrName>	
Patient signature		Referring GP Signature:		
Date		<TodaysDate>	Date		<TodaysDate>	

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>

If you require further information regarding the ITC program please contact:
			
Leanne Bryant
Integrated Team Care (ITC) Coordinator
l.bryant@bluecare.org.au
ph. 07 4161 1787  fax. 07 4161 1225