GP Details
<DrDetails>	Phone: <DrPhone>
Fax: <DrFax>	
Patient details
<PtDetails>
DOB: <PtDoB> Age: <PtAge>
Medicare Number: <PtMCNo> Patient’s ref no: <PtMCLine>
Pension/HCC No.:<PtPensionNo>	Home Phone: <PtPhoneH>
Work Phone: <PtPhoneWk>
Mobile Phone: <PtPhoneMob>
Patient Indigenous Identification: <PtEthnicity>	
		
To be completed by referring GP: (Please tick)
Chronic Disease Details <Chronic Disease Details> 
<Diagnosis - Diabetes (T1, T2, GDM)> Patient has Diabetes (T1, T2, GDM) AND/OR 		 
<Diagnosis - Cardiovascular Disease> Patient has Cardiovascular Disease AND/OR 		
 <Diagnosis - Respiratory Disease> Patient has Respiratory Disease AND/OR 			
<Other> 
Current Chronic Disease Management  <Current Management> 
<GP Management Plan (item 721 / review item 732) AND> Patient has GP Management Plan (item 721 / review item 732) AND
<Team Care Arrangements (item 723 / review item 732) OR> Team Care Arrangements (item 723 / review item 732) OR
<Multidisciplinary Care Plan for Aged Care Facility> GP has contributed to or reviewed a multidisciplinary care plan prepared by the patient’s aged care facility (item 731)

Note: Please attach a copy of the relevant care plan to this form.
Medicare rebates and Private Health Insurance benefits cannot be claimed for these services, however for eligible patients this service is fully funded.

Referral details – . The patient is considered to have limited access to multidisciplinary care from allied and other health professionals due to:  <Barriers to Healthcare> 
<Financial Barriers> Financial Barriers					<Health/Medical Barriers> Health/Medical Barriers
<Geographical Barriers (100km from service provider)> Geographical Barriers (>100km from service provider)	<Transport/Physical Access Limitation> Transport/Physical Access Limitations
<Social/Cultural Barriers> Social/Cultural Barriers					<English not First Language> English not First Language
<Patient has exhausted Medicare CDM Allied Health Visits> Patient has exhausted Medicare CDM Allied Health Visits
<Other (please specify):>
Supporting Comments:
<Supporting Comments>	

<Consent for ICDC Care Co-ordinator to make contact> The above patient has given consent to be contacted by the ICDC Care Co-ordinator to plan future multidisciplinary care.

Patient Signature: 	Date signed <TodaysDate>

Referring General Practitioner’s signature 	Date signed <TodaysDate>

This program aims to improve the health of vulnerable, disadvantaged or otherwise eligible individuals in the WA Country PHN Midwest region who suffer from chronic disease including and focusing on diabetes, cardiac or respiratory conditions