Referral Form for Individual Allied Health Services under Medicare for patients with a chronic medical condition and complex care needs
	
Note: GPs can use this form issued by the Department of Health or one that contains all of the components of this form.	
To be completed by referring GP:
Please tick:	
	Patient has GP Management Plan (item 721 ) AND Team Care Arrangements (item 723) OR	
	GP has contributed to or reviewed a multidisciplinary care plan prepared by the patient’s aged care facility (item 731)	
Note: GPs are encouraged to attach a copy of the relevant part of the patient’s care plan to this form.	
GP details	
Provider Number																  								
																								
Name				
			
Address		Postcode  		
Patient details	
Medicare Number																					Patient’s ref no.			
																								
First Name			Surname			
						
Address		Postcode  		
Allied Health Provider (AHP) patient referred to: (Please specify name or type of AHP)	
Name	REPS Movement

Address	3/71 Leach Highway, WILLAGEE, 6156 – Ph: 9319 8355 F: (08) 7079 5604
3/83 Catalano Circuit, CANNING VALE, 6155 – Ph: 6258 5822 F: (08) 7079 5604

			
Referral details – Please use a separate copy of the referral form for each type of service
Eligible patients may access Medicare rebates for a maximum of 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 Number		No of services	AHP Type	Item Number		No of services	AHP Type	Item Number		
		Aboriginal Health Worker/Aboriginal and Torres Strait Islander Health Practitioner	10950			Exercise Physiologist	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			
					
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 providers should retain this referral form for record keeping and Department of Human Services (Medicare) audit purposes.	
This form may be downloaded from the Department of Health website at www.health.gov.au/mbsprimarycareitems
	
THE FORM DOES NOT HAVE TO ACCOMPANY MEDICARE CLAIMS