Referral form for Allied Health Group Services inder Medicare for patient with Type 2 diabetes

Part A- To be completed by referring GP:	
Patient has Type 2 Diabetes: <<Patient has type 2 diabetes>>	
Item number claimed: <<Item number claimed>>

Note- Generally, residents of an aged care facility rely on the facility for assistance to manage their type 2 diabetes. Therefore, residents may not need to be referred for allied health group services as the self management approach may not be appropriate. 

GPs are encuraged to attach a copy of the relevant part of the patient's care plan to this form.
	
Please advise patients that Medicare rebates and Private Health Insurance benefits cannot both be claimed for this service.	
GP details:
Provider Number: <<Doctor:Provider Number>>
Name: <<Doctor:Name>>
Address: <<Doctor:Full Address>>	
Patient details:
First Name: <<Patient Demographics:First Name>>  
Surname: <<Patient Demographics:Surname>>
Address: <<Patient Demographics:Address>>
Phone Number: 
Mobile: <<Patient Demographics:Phone (Mobile)>>
Home: <<Patient Demographics:Phone (Home)>>	
Allied Health Practitioner (or practice) the patient is referred to for Assessment:
Name of AHP or practice: <<Addressee:Name>>
Address: <<Addressee:Full Address>>
Referring GP's signature:                                                               Date:	

Part B- To be completed by Allied Health professional who undertakes Assessment service:	
Eligible patients may access Medicare rebates for up to 8 allied health group services in a calendar year. group size must be between 2 and 12 persons.
Indicate the name of the provider/s, and details of the group service program;
Name of provider/s:
Name of program:
No. of sessions in the program:
Venue (if known):
Name of referring AHP:                                          Signature &  Date:	
AHPs must provide, or contribute to, a written report to the patient's GP after the Assessment service and at completion of the group services program.
AHPs should retain a copy of the referral form for record keeping and Medicare Australia audit purposes.
Allied Health Services funded by other Commonwealth or State/Territory programs are not eligible for medicare rebates under these items, except where the service is operating under sub-section 19(2) arrangements.
This form may be downloaded from the GP Association of Geelong website at www.gpageelong.com.au. 	
THIS FORM DOES NOT HAVE TO ACCOMPANY MEDICARE CLAIMS