Referring GP details
Name
Phone number / Email
Practice name
Practice address
Source of referral / o General Practice / o Community controlled health service
Program Eligibility
This Practice is participating in the / Yes o No
Practice Incentive Program-
Indigenous Health Incentive (PIP-IHI)
The client has a care plan / o Yes - Please attach with referral both 721 & 723
The client’s chronic disease/type / o Diabetes o Cardiovascular disease
(tick one or more as appropriate) / o Chronic respiratory disease o Cancer
o Chronic Renal disease
o Other______
Client details / ATSI / o YES / o NO
Surname / Given name
Date of birth / _ _ _/_ _ _/_ _ _ / Preferred name
Gender / o Female o Male / Medicare number (if available)
Residential address
(inc post code)
Phone number
The reason my client / o Is at significant risk of experiencing otherwise avoidable (lengthy
requires care / and/or frequent) hospital admissions
co-ordination services / o Is at risk of inappropriate use of services, such as hospital
(tick 1 or more as / emergency presentations
appropriate) / o Is not using community based services appropriately or at all
o Needs help to overcome barriers to access services
o Requires more intensive care co-ordination than is currently able
to be provided by general practice/Indigenous health service staff
o Is unable to manage a mix of multiple community based services
o Other ______
Referral authorised by
GP name, signature
and stamp
Date / _ _ _/_ _ _/_ _ _
Client Consent
Indicate who is consenting to collection, use and disclosure of personal health information.
Yes – Adult client is consenting
Yes – Child/adolescent client is consenting
Yes – Parent/guardian is consenting (on behalf of child/adolescent client)
Written client consent
My GP or care co-ordinator has discussed the CCSS program fact sheet with me. I understand what I have been told, any questions I had about the program have been satisfactorily answered and now I want 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 the personal information collected by these organisations 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 the 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 Torres Strait Islander people
Client / Parent / Guardian Name Signature Date
Or;
Verbal client consent
I have discussed the above points with the client regarding voluntary participation in the program, the collection and use and disclosure of relevant personal information, where this is required to assist in the management of care. I have also informed the client that non-identifying information may be collected and used to assist in improving the CCSS program.
I have discussed the proposed referral to the CCSS program with the client and am satisfied that the client understands and is able to provide informed consent to this.
GP/Care Co-ordinator Name Signature Date
Please send to: Tanisha Smitherson
Closing the Gap Team Leader
03 5126 2899