Referral Form for Individual Allied Health Services under Medicare for patients with a chronic medical condition and complex care needs	
To be completed by referring GP:  
Please tick:	
	Patient has GP Management Plan (item 721 or review item 732) AND Team Care Arrangements (item 723 or review item 732) 	
		
	GP has contributed to or reviewed a multidisciplinary care plan prepared by the patient’s aged care facility (item 731)	
Note: GPs are encouraged to attach a copy of the relevant part of the patient’s care plan to this form.	
Medicare rebates and Private Health Insurance benefits cannot both be claimed for these services.
Patients should be advised that they must choose whether to access one or the other.	
GP details	
Provider Number	 <<Doctor:Provider Number>>		
Name	 <<Doctor:Name>>			
Address	 <<Doctor:Address>>   <<Doctor:City>>	Postcode  <<Doctor:Postcode>>		
Patient details	
Medicare Number	 <<Patient Demographics:Medicare Number>>		
First Name	 <<Patient Demographics:First Name>>	Surname	 <<Patient Demographics:Surname>>		
Address	<<Patient Demographics:Address>>  <<Patient Demographics:City>>	Postcode  <<Patient Demographics:Postcode>>		
Allied Health Professional (AHP) patient referred to: (Please specify name or type of AHP)	
Name	 <<Addressee:Name>>		
Address	 <<Addressee:Address 1>>  <<Addressee:Address 2>>  <<Addressee:City>>	Postcode  <<Addressee:Postcode>>		
Referral details – Please use a separate copy of the referral form for each type of service
Eligible patients may access Medicare rebates for up to 5 allied health services (total) in a calendar year. Please indicate the number of services required by writing the number in the ‘No. of services’ column next to the relevant AHP.  	
	
No of services	
AHP Type	
Item Number	
	
No of services	
AHP Type	
Item Number	
	
No of services	
AHP Type	
Item Number	

	
Aboriginal Health Worker	
10950	

Exercise Physiologist	
10953	

Podiatrist	
10962	

	
Audiologist	
10952	

Mental Health Worker	
10956	

Psychologist	
10968	

	
Chiropractor	
10964	

Occupational Therapist	
10958	

Speech Pathologist	
10970	

		Diabetes Educator	10951			Osteopath	10966		
		Dietitian	10954			Physiotherapist	10960					
					
Referring General 
Practitioner’s signature			

Date signed	

	
					
The AHP must provide a written report to the patient’s GP after the first and last service, and more often if clinically necessary.	
Allied health professionals should retain this 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 this initiative.	
This form may be downloaded from the Department of Health and Ageing website at www.health.gov.au/mbsprimarycareitems	
THE FORM DOES NOT HAVE TO ACCOMPANY MEDICARE CLAIMS