General Practitioner Referral Form
IWC - ITC (Integrated Team Care) Program
     
Please fax completed form to (07) 3523 5944
 OR 
send via Medical Objects to - ITC IWC - North Burnett (II467000070)

	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 for the Indigenous Health Incentive? <Is patient registered for the Indigenous Health Incentive?>
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?>
Date of 715 Assessment: <Date of 715 assessment?>   
This patient has a current GP Management Plan and/or Team Care Arrangement? <Patient has a current GPMP and or TCA? (must be completed to be eligible)>   
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): <Please specify chronic disease details:> 
Has the patient accessed any alternative funding sources to support their chronic disease management? <Has the patient accessed alternative funding to support their chronic disease management?>
Has the patient accessed any of the following programs: <If yes, which services has the patient accessed?>
Please list any other funded services the patient has accessed to support their chronic disease management (not included above): <Other funded services patient has accessed to support their Chronic Disease Management?>

Reason for Referral:
Referral to Specialist: <Reason for Referral - Referral to Specialist?> (Please attach copies of Referrals to Specialist as required)
Specialist Discipline: <Specialist Discipline (multi-selection allowed)>
Identify name/s of specialist: <Identify name/s of specialist:>  
Allied health discipline: <Allied health discipline (multi-selection allowed)>
Identify name/s of allied health providers: <Name/s of allied health providers:>
Medical Aids required: <Aid/s and/or appliances requested-can select more than one>
Please list aids or appliances 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? <Can we Provide  your Client with a copy of the GPMP>

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 Australian Privacy Principles (APPs). 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 IWC 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:
			
Emma Madden - ITC Care Coordinator

Ph: 07 4199 7645  Email: itc-nb@iwc.org.au

IWC would like to acknowledge PHN for funding this initiative

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Past history list (selected)
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Investigation reports
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