Referral Form – Allied Health Program Woorabinda    

Email to: 	ITCreferral@yoonthallaservices.com

Program Eligibility: 	
My Aged Care Package	YES       NO
	
Does this person have a completed 715 health assessment (MBS 715) in the last 9-12 mths	YES       NO
	Is a copy of the completed health assessment attached?	YES       NO
	
Does this person have a current GP Management Plan and/or Team Care Arrangement	 YES       NO
	Is a copy of the completed GPMP / TCA attached?	YES       NO
	
Does this person have a chronic disease (please add one or more as appropriate)		
Reason for Referral (please circle)	*Diabetes Educator  *Dietitian  *Exercise Physiologist  *Occupational Therapist  *Physiotherapist  *Podiatrist  	
Referral date: 	Referrer Name:	
GP details: 		
Provider Number:		
Patient details:			
Surname: 	First Name: 	Date of Birth: 	Gender: 	
Does this patient Identify as: (please circle)	Aboriginal  Torres Strait Islander  Both  None   
(if none, do not proceed with the referral)       	Medicare Number: 

Medicare Expiry: 	
Address              		

	
Phone		
Patient Information and Consent: 	My GP/Aboriginal Health Worker/Nurse has discussed the Allied Health Program with me. I understand what I have been told, any questions I had about the Program have been satisfactorily answered and I want to participate. 
•	I understand that my participation is voluntary and that I have the right to withdraw from the Program at any time.
•	I understand that a range of health and community service providers may collect, use and disclose my relevant personal information as part of my care.
•	I understand that the personal information collected by these organisations will be maintained consistent with National Privacy Principles. It will remain confidential except when it is a legal requirement to disclose information; or where failure to disclose information would place me or another person at risk; or when my written consent has been obtained to release the information to a third party.	
Patient signature		Referrer Signature:		
Date			Date