General Practitioner Referral Form
Closing the Gap – ITC (Integrated Team Care) Program
     
please fax completed form to (07) 3523 5944 

Program Eligibility:	
Is this patient currently registered in the Indigenous Health Incentive?	<<Patient registered in Indigenous Health Incentive?>>	
This patient has completed a health assessment (MBS 715) in the last 9-12 mths (needs to be completed to be eligible)	<<Health assessment (MBS715) in last 9-12 mths?>>	Is a copy of the 715 Health assessment attached?
<<Copy of health assessment (MBS715) attached?>>	Date of assessment
<<Date of health assessment?>>	
This patient has a current GP Management Plan and/or Team Care Arrangement	<<Current GPMP and/or TCA?>>	Is a copy of the completed GPMP / TCA attached?
<<Copy of completed GPMP/TCA attached?>>		
The patient’s chronic disease type/s - can be more than one (e.g. Chronic respiratory, cardiovascular, diabetes, chronic renal disease, cancer, arthritis, sleep apnoea, gynaecology)	<<Patient chronic disease type/s (please list)>>

Reason for referral
(Please attach copies of referrals to specialists as required)

Medical Aids
Dose Administration Aids
Assistive Breathing Equipment
CPAP Machines
Accessories for CPAP Machines
Medical Footwear
Other
	Refer to specialist? <<Refer to Specialist?>>
Name of specialist: <<Name of Specialist>>
Specialist discipline: <<Specialist Discipline>>

<<Medical Aids required?>>
<<Dose Administration Aids (DAAs)>>
<<Assistive Breathing Equipment>>
<<CPAP Machines>>
<<Accessories for CPAP Machines>>
<<Medical Footwear>>
<<Other>>	
Referral date:	<<Date of referral>>	
Referring GP and provider number:	<<Doctor:Name>>     <<Doctor:Provider Number>>	
Practice name	<<Practice:Name>>	
Practice Address	<<Practice:Address>>	
Source of referral	General Practice	
Patient details:	
Surname: 
<<Patient Demographics:Surname>>	Firstname: 
<<Patient Demographics:First Name>>	DOB: <<Patient Demographics:DOB>>
Gender:<<Patient Demographics:Gender>>	
Does this patient identify as:	<<Patient identifies as>>	Medicare number: <<Patient Demographics:Medicare Number>>
Expiry date: <<Patient Demographics:Medicare Expiry Date>>
Health care card number: 
Pension number: <<Patient Demographics:Pension Number>>
DVA card type:
DVA card number: <<Patient Demographics:DVA Number>>	
Address	Residential: <<Patient Demographics:Address>>	

Postal: <<Patient Demographics:Address Postal>>	

Phone number	Home: <<Patient Demographics:Phone (Home)>>	Work: <<Patient Demographics:Phone (Work)>>	Mobile: <<Patient Demographics:Phone (Mobile)>>	
Reason/s patient requires Care Coordination services

Care Coordination required?
To avoid hospital admissions
To avoid inappropriate use of services
Better use of community services
Overcome barriers to access services
Intensive care coordination required	

<<Care Coordination (CC) required?>>
<<CC required to avoid hospital admissions>>
<<CC to avoid service missuse (eg A+E presentations)>>
<<CC to improve use of community based services>>
<<CC to overcome barriers to access services>>
<<CC needs beyond capacity of GP staff to meet>>	
Reason/s patient requires Supplementary Services

Supplementary Services required?
To address risk factors
To avoid hospital admission
To reduce length of stay in hospital
Other funding sources unavailable
For transport to clinical service
Medical Item	

<<Supplementary Services (SS) required?>>
<<SS to address risk factors such as long waits>>
<<SS to reduce chance of hospital admission>>
<<SS to reduce length of stay in hospital>>
<<SS required as other funding sources unavailable>>
<<SS to facilitate local transport to clinical service>>
<<SS required for Medical Item>>	
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	<<Patient Demographics:First Name>> <<Patient Demographics:Surname>>	Referral GP Name	<<Doctor:Name>>	
Patient consent obtained	<<Patient consent obtained>>			
Date	<<Date of consent>>			

* We may provide your patient with a copy of their GPMP & 715 Health Assessment as part of our intake assessment.
If you require further information regarding the ITC program please contact:
			
Emma Madden
Integrated Team Care (ITC) Coordinator
itc-nb@iwc.org.au
ph. 07 4199 7645  fax. 07 3523 5944