GP Details
<<Doctor:Full Details>>	Phone: <<Doctor:Phone>>
Fax: 	
Patient details
<<Patient Demographics:Full Name>>
<<Patient Demographics:Full Address>>
DOB: <<Patient Demographics:DOB>>Age: <<Patient Demographics:Age>>
Medicare Number: <<Patient Demographics:Medicare Number>>
Pension/HCC No.:<<Patient Demographics:DVA Number>>	Home Phone: <<Patient Demographics:Phone (Home)>>
Work Phone: <<Patient Demographics:Phone (Work)>>
Mobile Phone: <<Patient Demographics:Phone (Mobile)>>
Patient Indigenous Identification: <<Patient Demographics:Ethnicity>>	
		
To be completed by referring GP: (Please tick)
Chronic Disease Details <<Chronic Disease Details>>
<<Patient has Diabetes>> Patient has Diabetes (T1, T2, GDM) AND/OR 
<<Patient has Cardiovascular Disease>> Patient has Cardiovascular Disease AND/OR 		
<<Patient has Respiratory Disease>> Patient has Respiratory Disease AND/OR
 Other Conditions: <<Other (please specify)>>		

Current Chronic Disease Management  <<Current Management>>
<<Patient has GP Management Plan (item 721 / revie>> Patient has GP Management Plan (item 721 / review item 732) AND
<<Team Care Arrangements (items 723 / 732)>> Team Care Arrangements (item 723 / review item 732) OR
<<Aged Care Facility Care Plan (item 731)>> 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 Health Care>>
<<Financial Barriers>> Financial Barriers	
<<Health/Medical Barriers>> Health/Medical Barriers
<<Geographical Barriers (>100km from providers)>>  Geographical Barriers (>100km from service provider)
<<Transport/Physical Access Limitations>>  Transport/Physical Access Limitations
	<<Social/Cultural Barriers>> Social/Cultural Barriers	
<<English not First Language>> English not First Language
<<Patient exhausted Medicare CDM Allied Health>> Patient has exhausted Medicare CDM Allied Health Visits
Other Barriers <<Other (please specify)>>
	
Supporting Comments:
<<Supporting Comments>>	

<<Consent for ICDC 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 <<Miscellaneous:Date (short)>>

Referring General Practitioner’s signature 	Date signed <<Miscellaneous:Date (short)>>
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