Recommendation* I want to recommend my patient for: Recommended if your patient has a low level of Comprehensive assessment by an Aged Complete function and would benefit from access to a Home Care Assessment Team (ACAT) section A Care Package, Transition Care or Residential Care Recommended if your patient has a high level of Home support assessment by the Complete function and would benefit from access to CHSP Regional Assessment Service (RAS) section B services Section A: Recommended for ACAT Assessment Please complete and fax to your ACAT To support aged care assessment, please specify the aged care programs your patient would benefit from: Residential Care Residential Respite Transition Care Program Home Care Package Hospital Usual residence Location of Assessment Other (please specify): Section B: Recommended for RAS Assessment (CHSP Services) Please complete and fax to My Aged Care 1800 728 174 To support aged care assessment, please specify the types of services the patient would benefit from: Community Nursing Transport Meals Personal Care Domestic Assistance Home Modifications Allied Health, please specify: Other, please specify: Short term (< 6 weeks) Medium term (6 12 weeks) Long term (> 12 weeks) Estimated duration of services: – Date Services Required: Additional Information Yes Have you attached relevant case information including allied health assessments, wound care details, discharge summaries, care plans or relevant medical summaries? (please do not fax the client file) No Other comments:
Recommendation* I want to recommend my patient for: Comprehensive assessment by an Aged Care Assessment Team (ACAT) Complete section A Recommended if your patient has a low level of function and would benefit from access to a Home Care Package, Transition Care or Residential Care Home support assessment by the Regional Assessment Service (RAS) Complete section B Recommended if your patient has a high level of function and would benefit from access to CHSP services Section A: Recommended for ACAT Assessment Please complete and fax to your ACAT To support aged care assessment, please specify the aged care programs your patient would benefit from: Residential Care Residential Respite Transition Care Program Home Care Package Location of Assessment Hospital Usual residence Other (please specify): Section B: Recommended for RAS Assessment (CHSP Services) Please complete and fax to My Aged Care 1800 728 174 To support aged care assessment, please specify the types of services the patient would benefit from: Community Nursing Transport Meals Personal Care Domestic Assistance Home Modifications Allied Health, please specify: Other, please specify: Estimated duration of services: Short term (< 6 weeks) Medium term (6 – 12 weeks) Long term (> 12 weeks) Date Services Required: Additional Information Have you attached relevant case information including allied health assessments, wound care details, discharge summaries, care plans or relevant medical summaries? (please do not fax the client file) Yes No Other comments:
my_aged_care_hospital_fax_referral_form_170606_v0.1.docx