<<Miscellaneous:Practice Letterhead>>

TEAM CARE ARRANGEMENTS  - MBS ITEM No. 723	

Patient’s Name: <<Patient Demographics:Full Name>>	Date of Birth: <<Patient Demographics:DOB>>	

Contact Details:		Medicare or Private Health Insurance Details:	
<<Patient Demographics:Full Address>>	<<Patient Demographics:Medicare Number>>
<<Patient Demographics:Health Insurance>>	

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

	

Date of the last Care Plan / Team Care Arrangements (if done):  <<Date of last Care Plan/TCA>>

Other notes or comments relevant to the patient’s Team Care Arrangements: 

	

PAST MEDICAL HISTORY

FAMILY HISTORY

<<Clinical Details:Family History>>

MEDICATIONS 

<<Clinical Details:Medication List>>

ALLERGIES

Patient’s Name: <<Patient Demographics:Full Name>>

TEAM CARE ARRANGEMENTS  - MBS ITEM No. 723	

Goals - changes to be achieved	Required treatments and services including patient actions	Specific arrangements for treatments/services (when, who, and contact details)	

			

			

			

			

			

			

Copy of Team Care Arrangements offered to patient?  <<Copy of TCA offered to patient?>>

Team Care Arrangements added to the patient’s records?  <<TCA added to patient record?>>

Copy / relevant parts of the Team Care Arrangements supplied to other providers?  <<Copy of TCA supplied to other providers?>>

Referral forms for Medicare allied health and dental care services completed?  <<Referral forms for Medicare AHPs completed?>>
[For referral forms call 1800 067 307, go to www.hic.gov.au/providers/forms or look under "Supplied" templates] 

Date service was completed:  <<Date service completed>>	Proposed Review Date:  <<Review date (6 months recommended)>>	

I have explained the steps and any costs involved, and the patient has agreed to proceed with the Team Care Arrangements.  <<Steps and costs explained, patient agreed>>
The patient also agrees to the involvement of other health providers and to share their clinical information (without / with restrictions).  <<Patient agrees to AHPs and sharing information>>

 GP’s Signature:  ________________________________________________	Date:___________________