Purpose of this form

Patient registration
Complete Part A if you are a practice or Indigenous health service participating in the Practice Incentives Program (PIP) Indigenous Health Incentive and would like to register eligible Aboriginal and/or Torres Strait Islander patients for the Indigenous Health Incentive and/or the Pharmaceutical Benefits Scheme (PBS) Co-payment Measure.

For more information about the PIP Indigenous Health Incentive cultural awareness training, health checks and a definition of a 'usual practice' and 'chronic disease', refer to the PIP Indigenous Health Incentive Guidelines available at our website
humanservices.gov.au/healthprofessionals > Incentives and Allowances > Practice Incentive Program > Forms and guidelines

Registration
To be registered for the PIP Indigenous Health Incentive, the patient must:
•	identify as being Aboriginal and/or Torres Strait Islander origin
•	be 15 years of age or over
•	have a chronic disease
•	have a current Medicare card
•	have had, or been offered, the appropriate health check for Aboriginal or Torres Strait Islanders
•	provide consent that the practice is to be the patient's usual care provider and look after their chronic disease
To be registered for the PBS co-payment Measure, the patient must:
•	identify as being Aboriginal and/or Torres Strait Islander origin
•	be of any age
•	present with an exisiting chronic disease or chronic disease risk factor
•	in the opinion of the doctor, be likley to experience setbacks in the prevention or ongoing management of chronic disease if they did not take the prescribed medicine
•	be unlikley to adhere to their medicines regimen without assistance through this measure

Patient Consent
Complete Part B if you are Aboriginal and/or Torres Strait Islander origin and would like your doctor to provide better management of your chronic disease through the Practice Incentive Program (PIP) Indigenous Health Incentive and/or the Pharmaceutical Benefits Scheme (PBS) Co-payment Measure. 

PIP Online
Please read this information before answering the following question.

If you register the patient via PIP Online, Part B must be completed and retained at the practice.
Practice should only complete and return the form to Human Services if you are not registering the patient online.

1. Has this patient been registered for the Indigenous Health Incentive via PIP online?
<<Is pt registered Indigenous Incentive via PIP online>>

If Yes Go to Part B
If No, all parts of this form must be completed

Part A- Practice Details
2. Practice ID Number
<<Practice ID number>>

3. Practice Name
<<Practice:Name>>

4. Full practice address
<<Practice:Address>>

Patient registration requirements
5. Does this patient have a chronic disease?
<<Does pt has a chronic disease? >>

If Yes, the patient can be registered for the Indigenous Health Incentive and PBS Co- payment Measure.

If No, the patient is at risk of a chronic disease and can only be registered for the PBS co-payment Measure.

Note: Annual re-registration for the PBS Co-payment Measure is not required. However the patient must be re-registered annually for the PIP Indigenous Health Incentive. 

6. Has the patient had, or been offered, the appropriate health check for Aboriginal and Torres Strait Islander Australians?
<<Has the pt been offered/had a ATSI health check>>

If Yes, the patient can be registered for the Indigenous Health Incetive and the PBS Co-payment Measure.

If No, the patient cannot be registered for the Indigenous Health Incentive, but will be registered for the PBS Co-Payment Measure.

Note: If the patient is under 15 years they are not eligible to be registered for the Indigenous Health Incentive, but may be eligible for the PBS Co-payment Measure. Eligible patients will be registered for the PBS Co-payment Measure.

Privacy Declaration
15. Your personal information is protected by law, including the Privacy Act 1988. 
Personal information and other information about a practice that is participating in the Practice Incentive Program (PIP), or is applying to participate in the PIP, is collected by the Australian Government Department of Human Servicesfor the assessment and administration of PIP payments and services. This information will be disclosed to the Department of Health to enable that department to administer aspects of PIP, for statistical and research purposes and to inform policy development.
The Deparmtent of  Human Services may use or disclose your personal information for other purposes where that is required or authorised by law, or if you agree.
You can get more information about the way in which the Department of Human Services will manage your pesonal information, including our privacy policy, at  humanservices.gov.au/privacy or requesting a copy from the Department of Human Services.
.
Practice Declaration
16. I/We agree to:
• advise Human Services, in writing, of any changes to practice arrangements by the relevant 'point in time' date or within 14 calendar days, which ever date is earliest. 

I/We understand that:
• if this is not done, incentive payments may be reduced or recovered and the practice's eligibility for the PIP may be affected. 
• If all fields are not completed, this form can not be processed and will be returned to the practice.
• Giving false or misleading information is a serious offence. 

I/We  declare that:
• that patient has been fully informed of the PIP Indigenous Health Incentive and/or the PBS Co-Payment Measure.
• the information provided in this form is complete and correct.

General Practitioner's full name
<<Doctor:Name>>

General Practitioner's signature

	

Date <<Miscellaneous:Date (short)>>

 

	Register patients online:
Go to our website humanservices.gov.au/healthprofessionals and use your Public Key Infrastructure Certificate (PKI) to access Health Provider Online Services (HPOS).

For more information
For more information about the PIP go to our website humanservices.gov.au/healthprofessionals > Incentives and Allowances > Practice Incentive Program for details on the PIP guidelines refer to the Practice Incetive Program Guidelines at humanservices.gov.au/healthprofessionals > Incentives and Allowances > Practice Incetive Programs > Forms and guidelines
If you need assistance completing this form email pip@humanservices.gov.au or call 1800 222 032 Monday to Friday, between 8.30am and 5.00pm Australian Central Standard Time.
Note: Call charges apply from mobile phones. 

Returning your forms
Send the completed form to:

Department of Human Services
Practice Incentives Program
GPO Box 2572
ADELAIDE SA 5001

or 

Fax: 1300 587 696

Part B- Patient Details
7. Medicare card number
<<Patient Demographics:Medicare Number>> 

8. 
Title: <<Patient Demographics:Title>>
Patient's family name: <<Patient Demographics:Surname>>
Patient's first given name:<<Patient Demographics:First Name>>
Patient's other given names:

9. Patient's Date of Birth
<<Patient Demographics:DOB>>

10. Patient's sex
<<Patient Demographics:Sex>>

11. Is the patient of Aborginial or Torres Strait Islander origin?
<<Is pt of Aboriginal or Torres Strait Islander origin?>>

If No, the patient cannot be registered for the Indigenous Health Incentive or the PBS Co-payment Measure. 

Patient Consent
12. I want the practice written on this form to be my usual care provider and look after my chronic disease and/or chronic disease risk factor.
<<Pt has consented to practice as usual care provider>>

If the patient did not consent they cannot be registered for the Indigenous Health Incentive at this practice. 

13. I have been told how participation in the PIP Indigenous Health Incentive will help my practice provide better care for my chronic disease. I understand what I have been told, and want this practice to register me for this program.
<<Pt consented for practice to register them for PIP>>

If No, you cannot be registered for the Indigenous Health Incentive at this practice but will be registered for the PBS Co-payment Measure if eligible.

14. I have been told how participation in the PBS Co-payment Measure will make my PBS medicines cheaper. I understand what I have been told, and I want this practice to register me for this program.
<<Pt has been told about PBS co-payment measure>>

If No, you will not be registered for the PBS Co-payment Measure at this practice.

17. The autorised contact person must be authorised by the owner(s) of the practice to advise us of changes and will be the person(s) to whom all correspondence is addressed. The authorised contact person(s) is responsible for notifying us in writing to any changes in practice arrangements by no later than 7 days prior to the relevant point-of-time date.

Authorised contact person's full name

Authorised contact person's position held

Authorised contact person's signature

Date
<<Miscellaneous:Date (short)>>

Patient declaration
18. I acknowledge and consent that:
• my personal details on this form will be shared between this practice, the Australian Government Department of Human Services and the Department of Health for the purposes of the PIP Indigenous Health Incentive and/or the PBS Co-payment Measure.

I understand that:
• general participation information (which is not linked to my name or other personal details) will be used to see how well the program is working and help improve services for Aboriginal and Torres Strait Islander people.
• I can withdraw my consent to participate in the PIP Indigenous Health Incentive and/or the PBS Co-payment Measure at any time.
• giving false or misleading information is a serious offence.

I declare that:
• The information provided in this form is complete and correct.

19. Patient or parent/guardian's full name

Patient or parent/guardian's signature

Date
<<Miscellaneous:Date (short)>>