CHRONIC DISEASE MANAGEMENT
GP MANAGEMENT PLAN & TEAM CARE ARRANGEMENTS (MBS ITEM No. 721 & 723)

ITEM 721 and 723 COMBINED FORM
Patient’s Name:       <<Patient Demographics:Full Name>>	Date of Birth:      <<Patient Demographics:DOB>>	
Contact Details:	Medicare No.:    <<Patient Demographics:Medicare Number>>	
<<Patient Demographics:Full Address>>	Private Health Insurance Details:    	
Phone:	(H) <<Patient Demographics:Phone (Home)>> (W) <<Patient Demographics:Phone (Work)>>		

Details of Patient’s Usual GP:	Details of Patient’s Carer (if applicable):	
<<Doctor:Full Details>>		

If the patient has a previous or existing care plan, when was it prepared and what were the outcomes?

Other notes or comments relevant to the patient's care planning:

HISTORY LIST

MEDICATIONS
<<Clinical Details:Medication List>>	
ALLERGIES:  <<Clinical Details:Allergies>>

CURRENT PROGRESS NOTES:
<<Summary:Progress Note (Current)>>	
FAMILY HISTORY:
<<Clinical Details:Family History>>	SOCIAL HISTORY:
<<Clinical Details:Social History>>	

Patient's Name: <<Patient Demographics:Full Name>>					GP MANAGEMENT PLAN	

Patient problems/ needs/ relevant conditions	Goals - changes to be achieved
	Required treatments and services including patient actions.
	Arrangements for treatment / services (when, who, contact details)
	
<<Patient problem/ needs - GPMP Goal 1>>	<<Changes to be achieved - GPMP Goal 1>>

<<Patient problem/ needs - GPMP Goal 2>>	<<Changes to be achieved - GPMP Goal 2>>

Other problems:
<<Other problems>>	<<Other changes to be achieved>>

Copy of GPMP offered to patient?   YES

Copy or relevent parts of GPMP supplied to other providers?   YES

GPMP added to the patient’s records?   YES

Date service was completed: 	<<Date GPMP service completed>>
Review Date:	<<GPMP Review Date>>

I have explained the steps and costs involved, and the patient has agreed to proceed with the service. The patient also agrees to the involvement of other health providers and to share their clinical information without / with restrictions: 

GP Signature:              ...................................................          Date:  ...................................................	GP Name:  <<Doctor:Name>>

I give my permission for my GP to discuss my medical history/diagnosis with other service providers.
I understand that referral for service can still go ahead if I do not want information about me made known to the service.

Patient/Carer Signature ....................................................................         Date:       /            /

Copy of Plan provided to patient: YES
I unerstand the above Management Plan recommendations and agree to the outlined goals.	Any information the patient wants withheld:
<<Any information the patient wants withheld?>>
Details (if necessary):

Eligible for TCA: <<Eligible for TCA>>

Patient's Name: <<Patient Demographics:Full Name>>	TEAM CARE ARRANGEMENTS	

Goals - changes to be achieved	Required treatments and services including patient actions.	Arrangements for treatment / services (when, who, contact details)	
<<Changes to be achieved - GPMP Goal 1>>

	
<<Changes to be achieved - GPMP Goal 2>>

	
Other changes to be achieved:
<<Other changes to be achieved>>	

Copy of TCA offered to patient?  YES

Copy / relevant parts of the TCA supplied to other providers?   YES

TCA added to the patient’s records?   YES

Referral forms for Medicare allied health and dental care services completed?   <<Referral forms completed?>>
[For paper referral forms call 1800 067 307. For MD template forms go to: http://www.nevdgp.org.au/?content=14] 

Date service was completed: <<Date TCA service completed>> 
Review Date:			<<TCA Review Date>>