Wide Bay Hospital and Health Service
Bundaberg & Rural Health Service

Private Practice Request For Procedure To Be Completed At Public Hospital	(Affix identification label here)

URN: 
Family name: <<Patient Demographics:Surname>>
Given Name(s): <<Patient Demographics:First Name>>
Address: <<Patient Demographics:Address>>
Date of birth: <<Patient Demographics:DOB>>
Sex: <<Patient Demographics:Gender>>	
This form must be completed by the Private Practice when requesting 
a procedure to be completed at a Public Hospital of the Wide Bay Hospital & Health Service.

This form can be faxed to the Public Hospital 
or given to your patient to bring with them when presenting to the Public Hospital.	
Requesting Private Practice Details	
Private Practice Name: <<Practice/Location:Name>>
Address: <<Practice/Location:Address>>
Phone/Fax: <<Practice/Location:Phone>> / <<Practice/Location:Fax>>
Requesting Doctor: <<Doctor:Name>>
Provider Number: <<Doctor:Provider Number>>	
Patient Details	
Patient Name: <<Patient Demographics:Full Name>>
Address: <<Patient Demographics:Address>>
DOB: <<Patient Demographics:DOB>>	
Requesting Procedure Details	
Procedure Required: 

Date Required: 
Medicare Item Number: 	
Additional Information	

Public Hospital Use Only	
Upon completion of the procedure, please forward this form to Administration Officer of the Public Hospital