This form is for Referral only. If you are seeking prior approval for treatment of a veteran, use Form D1328 – Treatment Prior Financial Approval Request Form.
All information requested on this form must be provided.
Please complete the patient’s details, including address and date of birth if file number is not known.
This form should be used by the referring provider to:
• refer directly for treatment services
• refer directly to another provider where prior approval from DVA is not required.
For detailed information on DVA’s prior approval and other administrative requirements, please refer to the booklet ‘Notes for GPs’, ‘Notes for Allied Health Providers – Section One – General’ or contact DVA by phone.
Where bulk referral is appropriate, please send any necessary clinical details directly to the provider.
The GP is responsible for checking the eligibility of patients to receive treatment at DVA expense.
White card holders are entitled to receive treatment at DVA expense for their accepted disabilities only.
DVA will not be responsible for costs incurred where prior approval requirements are not followed, where ineligible patients are treated, or where a patient is treated by a provider who is not authorised to provide treatment on behalf of DVA.
If an indefinite referral to a medical specialist is appropriate for a chronically ill patient, the period of referral may be noted on the form as “ind”. Note this is not applicable for referrals to Allied Health Providers, see information on the Treatment Cycle on
page 2.
	
Referral type	
1. Referral type	<Referral type>	

Patient details	
2. Surname	<PtSurname>	
3. Given name(s)	<PtFirstName> <PtMidName>	
4. DVA file number	<PtDVANo>	
5. Date of birth	<PtDoB>	
6. Address	<PtAddress>	
7. Email address	<PtEmail>	
8. Phone number	home: <PtPhoneH>          mobile: <PtPhoneMob>	
9. Card type	<PtDVACard>	
10. Accepted disabilities	<Accepted disabilities>	

11. Referral to	<Referral to>	
Name	<Name>	
Address	<Address>	
Email address	<Email address>	
Phone number	<Phone number>	
Mobile number	<Mobile number>	
Provider number (if known)	<Provider number (if known)>	

12. Condition to be treated	<Condition to be treated>	

13. Is the patient a resident in a Residential Aged Care Facility?	<Is the patient a resident in a Residential Aged Care Facility?>
If yes, provide level of care patient is funded to receive and the date the funding began
Level of care: <Level of care (if applicable)>
Date funding began: <Date funding began (if applicable)>	

14. Clinical details of condition including recent illnesses, injuries and current medication, if applicable
Attach additional details 
(if applicable)	<Clinical details of condition including recent illnesses, injuries and current medication, if applicable>	

Treatment Cycle
 <Treatment Cycle> 	

15. Period of referral
Please refer to the information on the Treatment Cycle above	<Period of referral (Please refer to the information on the Treatment Cycle above)>	

16. Other treating health providers
(if relevant)	<Other treating health providers (if relevant)>	

Referring provider details	
17. Provider name	<DrName>	
18. Provider number	<DrProviderNo>	
19. Practice name	<Practice>	
20. Practice address	<UsrAddress>	
21. Email address	<PracEmail>	
22. Phone number	<UsrPhone>	Fax number	<UsrFax>	
23. Provider signature	
	Date	<TodaysDate>	

Allied health providers should retain this referral form for record keeping and 
Department of Veterans' Affairs audit purposes.