Referral form for Group Allied Health Services under Medicare
 for patients with type 2 diabetes	
Note: GPs can use this form issued by the Department of Health or one that contains all of the components of this form.	
PART A – To be completed by referring GP (tick relevant boxes):	
	Patient has type 2 diabetes  AND either 	
	GP has prepared a new GP Management Plan (MBS item 721) OR

	
	GP has reviewed an existing GP Management Plan (MBS item 732) OR
	
   for a resident of a residential aged care facility, GP has contributed to or reviewed a care plan prepared by the residential aged care facility (MBS item 731) [Note: Residents of residential aged care facilities may rely on the facility for assistance to manage their type 2 diabetes. Therefore, residents may not need to be referred for allied health group services as the self-management approach may not be appropriate.]
Note: GPs are encouraged to attach a copy of the relevant part of the patient’s care plan to this form.	
Please advise patients that Medicare rebates and Private Health Insurance benefits cannot both be claimed for this service	
GP details 	
Provider Number	 		 		 		 		 		 		 		 									
																									
Name	     			
			
Address	     	Postcode      		
Patient details	
First Name	     		Surname	     		
						
Address	     	Postcode      		
Note: Eligible patients may access Medicare rebates for one assessment for group services in a calendar year.  Indicate the name of the practitioner (diabetes educator, exercise physiologist or dietitian), or the allied health practice, you wish to refer the patient to for this assessment.  The assessment must be done before the patient can access group services. 	
Allied Health Practitioner (or practice) the patient is referred to for assessment: 	
Name of AHP or practice	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

					
Referring GP’s signature					
		Date		

					
PART B – To be completed by allied health provider (AHP) who undertakes assessment service:
Eligible patients may access Medicare rebates for up to 8 allied health group services in a calendar year. 
Group size must be between 2 and 12 persons.  
Indicate the name of the provider/s, and details of the group service programme.  

Name of provider/s:                       

Name of programme: 

  
No. of sessions in programme: 

Venue (if known):

Name of referring AHP:                                                                                Signature  
                                                                                                                         and date	

Allied health providers must provide, or contribute to, a written report to the patient’s GP after the assessment service and at completion of the group services programme.  Allied health providers should retain a copy of the referral form for record keeping and Department of Human Services (Medicare) audit purposes.  Allied health services funded by other Commonwealth or State/Territory programmes are not eligible for Medicare rebates under these items, except where the service is operating under sub-section 19(2) arrangements.
This form may be downloaded from the Department of Health website at www.health.gov.au/mbsprimarycareitems.
	
THIS FORM DOES NOT HAVE TO ACCOMPANY MEDICARE CLAIMS	
		Diabgrp 0510