<PracticeLetterhead>

<TodaysDate>

<AdrName>
<AdrAddress>
Phone: <AdrPhone>
Fax: <AdrFax>

Dear <AdrGreeting>,

Re:  Team Care Arrangements for  <PtFullName>,  DOB: <PtDoB>

The Commonwealth Government through the Enhanced Primary Care initiative aims to improve coordination of care and provide a more systematic approach to the care of patients with chronic conditions and complex care needs.  One component of this initiative provides GPs with an opportunity to develop multidisciplinary Team Care Arrangements for these patients.

I am currently developing Team Care Arrangements for the above patient who has given consent to include you as a member of the team.  Attached is a copy of the plan.

I would be grateful if you could advise me:
a) Whether you are willing to be involved in the Team Care Arrangements for this patient?
b) Whether you are satisfied with the plan or have any suggestions for changes to the Team Care Arrangements?

I would appreciate your feedback either by phone or by completing the details below and faxing this page back to me.  If you are happy with the plan all you need to do is to fax this page back and send feedback as per usual after you have seen the patient.

Yours sincerely

_____________________________________________________________________

Communication re team care arrangement
I, <AdrName>, in reference to the Team Care Arrangements for this patient
(Please tick boxes as appropriate)
p  I am willing to be involved in the Team Care Arrangements, and I am satisfied with the plan as it is.
p  I am willing to be involved in the Team Care Arrangements, and I would like to make some changes to the plan (please attach your suggested changes).

Signature: ………………………………………….		Date:  …../…../…..

  	
Enhanced Primary Care (EPC) Program 
Referral Form for Allied Health Services under Medicare 	
To be completed by referring GP
Please tick the relevant box below:
 Patient has a GP Management Plan and Team Care Arrangements in place (new CDM MBS items 721 AND 723) 
OR
     Patient has an EPC Multidisciplinary Care Plan in place (former MBS items 720, 722 or 730; or new CDM item 731)
Note: GPs are encouraged to attach a copy of the relevant part of the patient’s care plan to this form.	
Medicare rebates and Private Health Insurance benefits cannot both be claimed for these services.
Patients should be advised that they must choose whether to access one or the other.	
GP details	
Provider Number	<DrProviderNo>	NOTE: Relevant MBS item(s) above must be BILLED by GP prior to patient receiving their first referred allied health service for Medicare rebate to be payable for that service.	
Name	<DrName>		
Address	<DrAddress>		
Patient Details		
Medicare Number	<PtMCNo>			Patient’s Ref. No.	<PtMCLine>	
First Name	<PtFirstName>		Surname	<PtSurname>	
Address	<PtAddress>	
Allied Health Professional (AHP) patient referred to: (Please specify name or type of AHP) 	
Allied Health Professional	<AdrName>	
Address	<AdrAddress>	
Referral details – Please use a separate copy of the referral form for each type of service
Eligible patients may access Medicare rebates for up to 5 allied health services (total) in a calendar year. Please indicate the number of services required by writing the number in the ‘No. of services’ column next to the relevant AHP.	
No of services	AHP Type	Item  No.		 No of services	AHP Type	Item No.		No of services	AHP Type	Item No.	
	Aboriginal Health Worker 	10950			Exercise Physiology	10953			Podiatrist	10962	
	Audiologist	10952			Mental Health Worker 	10956			Psychologist	10968	
	Chiropractor	10964			Occupational Therapist 	10958			Speech Pathologist	10970	
	Diabetes Educator	10951			Osteopath	10966					
	Dietitian	10954			Physiotherapist	10960					
			
Referring General 
Practitioner’s signature			Date Signed:	<TodaysDate>	   	
AHP must provide a written report to patient’s GP after each service – except where the AHP provides multiple services to a patient  under the one referral. In this case, the AHP must provide a written report to the patient’s GP after the first and last service, and more often if clinically necessary.	
Allied health professionals should retain this referral form for record keeping and Medicare Australia audit purposes.	
Allied health services funded by other Commonwealth or State/Territory programs are not eligible for Medicare rebates under
this initiative	
THIS FORM DOES NOT HAVE TO ACCOMPANY MEDICARE CLAIMS