Referral Form Integrated Team Care
(Previously Called: Closing the Gap)
If you consider this referral a high priority please call our office after faxing the referral
Eligibility
Patient identifies as Aboriginal and/orTorres Strait Islander / Yes No – Not eligible for the program
This patient has a care plan:
Aboriginal Health Check 715, GPMP 721
and/or Team Care Arrangement 723 / Yes (please attach) a signed care plan
(Please ensure patient goals are clearlydefined) (A GPMP
(721) is mandatory for access to the CCSS program)
The patient’s chronic disease type/s
(tick one or more as appropriate for CCSS
program) *To be consistent with the MBS,
an eligible condition is one that has been,
or is likely to be, present for at least six months. / Diabetes Cardiovascular Disease Cancer
Chronic Respiratory Disease Chronic Renal Disease
Other Chronic Disease* (not dental)
Referral Date:
Persons Details
First Name / SurnameDOB / Gender
Address / Postcode
Phone (work) / Phone (home) / Mobile
Indigenous Status / Interpreter Required Yes No
Medicare Card # Ref # / Expiry / Health Care Card # / Expiry
Applicable Private Health Insurance? Yes No
Contacts (Complete relevant field/s)
Next of Kin/ Emergency/ Guardian Contact:
Name / Phone
Address / Postcode
Relationship to person:
Carer Details: (if applicable)
Name / Phone
Referrer Details (if applicable)
NameOrganisation
Address / Postcode
Fax / Provider Number
Referral Information
Reason for Referral
Diagnosis
Allergies
Current Medications (Please attach medications summary)
Relevant medical history/conditions (Please attach health summary )
Referral type / Referral Activity / Eligibility requirements
Indigenous Health CareWorker (IoW) / Health promotion/education / Aboriginal or Torres Strait Islander
Please note that a
referral to an IOW does
not have to be related
to a chronic disease.
715 Health Check promotion/facilitation & follow-up
Assistance to access services and attend health related appointments
Transport assistance by IoW (health related only – e.g. health appointment, blood test) (excludes financial assistance e.g. taxi)
Support during appointment consultation/s
Collect Prescribed medications
Assistance filling out health related forms
Chronic Disease / Diabetes / Cardiovascular Disease / Cancer
Chronic Respiratory Disease / Chronic Renal Disease
(except dental) / other please specify
CareCoordination(CC) / Care Co-ordination of required services outlined in the GPMP in consultation with GP/ Practice / Aboriginal or Torres Strait Islander
Enrolled for Chronic disease* management with GP/AMS
Attached GPMP
Provide clinical support (consistent with skills of CC)/ education /encourage adhere to treatment regimens
AssistClient to participate in primary care providers reviews and care plan compliance
Assist Client to develop chronic condition self-management skills
Assist client with other service support community based connections
Supplementary Services / Transport assistance inclusive of taxi vouchers to attend health related appointments / +Care Coordination Services referral
Transport assistance to closest regionally available health care professional, where this is necessary in order to access the required health care in a clinically appropriate timeframe / +Care Coordination Services referral
Other travel schemes exhausted
Medical specialist / +Care Coordination Services referral and
these services are not otherwise available in a clinically acceptable timeframe
Allied Health Services
Allowable Medical Aid / +Care Coordination Services referral
not available through other activity in clinical acceptable timeframe
related clients chronic disease
documented in GPMP
component of primary health care service
AMS clients to use QUMAX funding
Assisted breathing equipment (including asthma spacers; nebulisers; masks for asthma spacers and nebulisers; continuous positive airways pressure (CPAP) machines; accessories for CPAP machines)
Blood sugar/glucose monitoring equipment
Dose administration aids
Medical footwear prescribed and fitted by a podiatrist
Mobility aids (e.g., crutches, walking frames, or non-electric wheel chairs) or shower chairs
Spectacles (special conditions apply)
*A chronic condition for the purpose of the ITC Activity, and consistent with the MBS, an eligible condition is one that has been, or is likely to be, present for at least six months. Dental is not an eligible condition for the purposes of the ITC Activity.
ThereasonmypatientrequiresCareCoordinationand Supplementary Services(tick1ormoreasappropriate)
(By selecting items in this section an assessment will be conducted to determine eligibility for Supplementary Services)
likely to prevent hospital admission
likely to reduce hospital admission length of stay
risk of inappropriate use of services, such as hospital emergency presentations
needshelptoovercomebarrierstoaccessservices requiresmoreintensivecarecoordinationthaniscurrentlyableto beprovided bygeneralpractice/IndigenousHealthServicestaff
isunabletomanageamixofmultiplecommunitybasedservices
service requested is unavailable through other funding sources
waiting period for the service is longer than clinically appropriate
no availability of local transport for patient to attend specialist or allied health appointment
prohibitive transport cost for the patient to attend specialist or allied health appointment
other
Consent to referral:
My GP has discussed the ITC Program with me and provided relevant information. I understand what I have been told.
- I understand that my participation is voluntary and that I have the right to withdraw from the program at any time
- I understand that GP data (that will not identify me) will be collected and used to see how well the program is
working and help improve the program.
Referred person/ Carer/ Guardian name
Signature:
I have discussed the proposed referral to the ITC Program with the person and/or their guardian and am
satisfied that the person and/or their guardian understands this referral.
Referrer’s signature:______
Please attach ATSI Health Check (MBS 715), GPMP (721),
and/or Team Care Arrangement (723)
All referrals must be sent through to our secure fax
and will not be accepted through other referral means.
F: (07) 4421 7450
Northern Australia Primary Health Limited
ABN: 87063397231