Chronic Disease Management Program (CDMP) GP Referral Form Program eligibility: Does this person identify as: Aboriginal Torres Strait Islander Aboriginal & Torres Strait Islander The patient has completed a health Yes No a care plan and – assessment (MBS 715) in the last Is copy of completed health assessment health assessment are 9-12 months attached? required for access to this The patient has a current (within Yes program previous 6-12 months) GP Is a copy of the completed GPMP/TCA Management Plan and Team Care attached? Arrangement The patient’s chronic disease disease type/s (tick one or more as respiratory disease renal disease appropriate) (please specify) ______________________________ PIP-IHI Information: This practice is participating in the Practice Incentive Yes No Program–Indigenous Health Incentive (PIP-IHI) This patient is PIP-IHI registered Yes No This patient is Closing The Gap (CTG) registered Yes No Referring GP details: Name Phone number Email Practice name Practice street address Referral date _ _ _ / _ _ _ / _ _ _ Patient details: Surname First Name Gender Male Female Date of Birth _ _ _ / _ _ _ / _ _ _ Residential address Phone number Patient Observations Height:______ Weight: _______ Waist: _______ BMI: _______ BP: _______ (within the last 2 months) Pulse: ______ HbA1c: ________ ACR: _______ eGFR: _______ The reason my patient is at significant risk of experiencing otherwise avoidable (lengthy and/or requires Care Coordination frequent) hospital admissions services (tick 1 or more as is at risk of inappropriate use of services, such as hospital emergency appropriate) presentations is not using community based services appropriately or at all Please fax completed form to the NCACCH Chronic Disease Management Program on 5335 1272 or scan and email to Page 1 of 2
Chronic Disease Management Program (CDMP) GP Referral Form Program eligibility: Does this person identify as: Aboriginal Torres Strait Islander Aboriginal & Torres Strait Islander The patient has completed a health assessment (MBS 715) in the last 9-12 months Yes Is copy of completed health assessment attached? No – a care plan and health assessment are required for access to this program The patient has a current (within previous 6-12 months) GP Management Plan and Team Care Arrangement Yes Is a copy of the completed GPMP/TCA attached? The patient’s chronic disease type/s (tick one or more as appropriate) disease respiratory disease renal disease (please specify) ______________________________ PIP-IHI Information: This practice is participating in the Practice Incentive Program–Indigenous Health Incentive (PIP-IHI) Yes No This patient is PIP-IHI registered Yes No This patient is Closing The Gap (CTG) registered Yes No Referring GP details: Name Phone number Email Practice name Practice street address Referral date _ _ _ / _ _ _ / _ _ _ Patient details: Surname First Name Gender Male Female Date of Birth _ _ _ / _ _ _ / _ _ _ Residential address Phone number Patient Observations (within the last 2 months) Height:______ Weight: _______ Waist: _______ BMI: _______ BP: _______ Pulse: ______ HbA1c: ________ ACR: _______ eGFR: _______ The reason my patient requires Care Coordination services (tick 1 or more as appropriate) is at significant risk of experiencing otherwise avoidable (lengthy and/or frequent) hospital admissions is at risk of inappropriate use of services, such as hospital emergency presentations is not using community based services appropriately or at all Please fax completed form to the NCACCH Chronic Disease Management Program on 5335 1272 or scan and email to Page 1 of 2