the and Referral Date _ _ _/_ _ _/_ _ _ Referring GP details Name Phone number Email Practice name Practice address Source of referral Practice controlled health service General Community Program Eligibility This Practice is participating in the No Practice Incentive Program- Indigenous Health Incentive (PIP-IHI) - Please attach with referral both 721 Yes The client has a care plan & 723 The client’s chronic disease/type disease Diabetes Cardiovascular (tick one or more as appropriate) respiratory disease Chronic Cancer Renal disease Chronic _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Other_ Client details ATSI YES NO Surname name Date of birth Preferred name _ _ _/_ _ _/_ _ _ Female  Gender Medicare number (if available) Male Residential address (inc post code) Phone number The reason my client at significant risk of experiencing otherwise avoidable (lengthy Is requires care and/or frequent) hospital admissions co-ordination services at risk of inappropriate use of services, such as hospital Is (tick 1 or more as emergency presentations appropriate) not using community based services appropriately or at all Is Needs help to overcome barriers to access services  more intensive care co-ordination than is currently able Requires to be provided by general practice/Indigenous health service staff unable to manage a mix of multiple community based services Is _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Other Referral authorised by GP name, signature and stamp Date _ _ _/_ _ _/_ _ _
Referral Date _ _ _/_ _ _/_ _ _ Referring GP details Name Phone number Email Practice name Practice address Source of referral General Practice Community controlled health service Program Eligibility This Practice is participating in the No Practice Incentive Program- Indigenous Health Incentive (PIP-IHI) The client has a care plan Yes - Please attach with referral both 721 & 723 The client’s chronic disease/type Diabetes Cardiovascular disease (tick one or more as appropriate) Chronic respiratory disease Cancer Chronic Renal disease Other_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Client details ATSI YES NO Surname name Date of birth _ _ _/_ _ _/_ _ _ Preferred name Gender  Female Male Medicare number (if available) Residential address (inc post code) Phone number The reason my client Is at significant risk of experiencing otherwise avoidable (lengthy requires care and/or frequent) hospital admissions co-ordination services Is at risk of inappropriate use of services, such as hospital (tick 1 or more as emergency presentations appropriate) Is not using community based services appropriately or at all  Needs help to overcome barriers to access services Requires more intensive care co-ordination than is currently able to be provided by general practice/Indigenous health service staff Is unable to manage a mix of multiple community based services Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Referral authorised by GP name, signature and stamp Date _ _ _/_ _ _/_ _ _ the and
CCSS-PROGRAM-REFERRAL1.docx