GENERAL PRACTITIONER REFERRAL FORM
STAYING HEALTHY LIVING WELL PROGRAM –
A CESPHN initiative free of charge to patients delivered by Feros Care
 
PROVIDER DETAILS:
<<Addressee:Name>>
<<Addressee:Full Address>>
Phone: <<Addressee:Phone>>	

q Patient has GPMP (item 721 or review item 732) AND TCA (item 723 or review item 732)	
q 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.	

PATIENT DETAILS: 
Title: <<Patient Demographics:Title>>                           Surname: <<Patient Demographics:Surname>>	
Given name: <<Patient Demographics:First Name>>	Medicare No: <<Patient Demographics:Medicare Number>>	
	Patient Reference No: 	
Address: <<Patient Demographics:Full Address>>	Home Phone: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>	
English Spoken: <<English spoken>> (this service is only available to English speaking patients)	Date of Birth: <<Patient Demographics:DOB>>	Sex: <<Patient Demographics:Gender>>	
CLINICAL INFORMATION:
	
I would like your assistance in developing an appropriate Health Literacy and Wellbeing Action Plan program specific to their current medical, physical or other needs. 
I would like to draw your attention to this patient’s current medical condition:
Medical History List: <<Clinical Details:History List>>Current Medication: <<Clinical Details:Medication List>>Blood results: <<Summary:Investigation Results (Selected)>>

In my opinion, the above patient is suitable to participate in the Staying Healthy Living Well Program; however, I understand that you will undertake an assessment to ensure the action plan meets their current health needs.
I would appreciate a summary of your recommendations being forwarded to me after the first and last service, and more often if clinically necessary.
REFERRING GENERAL PRACTITIONER SIGNATURE: ..........................................................................
REFERRAL DATE: <<Miscellaneous:Date (short)>> 
<<Doctor:Name>>
Provider No.: <<Doctor:Provider Number>>
<<Doctor:Full Address>>
Phone: <<Doctor:Phone>>	

Referral can be sent to:	HealthLink EDI :ferosths		Fax: 1300 850 770
Email:                  SHLW@feroscare.com.au
Or call 1300 019 975 for further information.