Attention: Intake Fax: 1300 778 718 Telehealth for Chronic Disease Mgt. @ Home - Tasmania Consumer Surname First Name DOB: Gender: M/F/ identifies as:- Address Phone: Eligibility Cardiovascular Disease Criteria Diabetes Chronic Obstructive Pulmonary Diseases and Chronic Kidney Diseases Other (prolonged illness causing functional impairment minimal chance cure):- Reason for Consumer consent referral Yes No Cosnumers understanding of referral Person referring Position Organisation: Contact number:- GP Contact number Specialist Contact number Thankyou for the referral Integratedliving Processing Site RN – Date received Date Consumer contact Proceeding onto service:- made:- Yes No - Reason for not progressing:- ( File in consumer hard file or upload to (Enter into TRACCs with baseline consumer TRACCs and destroy) demographics and discharge file in TRACCs V1 9 5 16 1 of 1
Attention: Intake Fax: 1300 778 718 Telehealth for Chronic Disease Mgt. @ Home - Tasmania Consumer Surname First Name DOB: Gender: M/F/ identifies as:- Address Phone: Eligibility Criteria Cardiovascular Disease Diabetes Chronic Obstructive Pulmonary Diseases and Chronic Kidney Diseases Other (prolonged illness causing functional impairment minimal chance cure):- Reason for referral Consumer consent Yes No Cosnumers understanding of referral Person referring Position Organisation: Contact number:- GP Contact number Specialist Contact number Thankyou for the referral Integratedliving Processing – Site RN Date received Date Consumer contact made:- Proceeding onto service:- Yes ( File in consumer hard file or upload to TRACCs and destroy) No - Reason for not progressing:- (Enter into TRACCs with baseline consumer demographics and discharge file in TRACCs V1 9 5 16 1 of 1