Referral form for follow-up allied health services under Medicare for People of Aboriginal or Torres Strait Islander descent

To be completed by referring GP
Health assessment completed: (delete items not applicable) 701	   703	705	707	715
GP details		
Provider number	<DrProviderNo>	
Name	<DrName>	
Address	<DrAddress>	

Patient details	
Medicare number	<PtMCNo>	Patient’s ref 	<PtMCLine>	
First name	<PtFirstName>	Surname 	<PtSurname>	
Address 	<PtStreet>	Postcode <PtPostcode>	

Allied health professional (AHP) patient referred to: Specify name or type of AHP	
Name 	<AdrName>	
Address 	<AdrStreet>	Postcode <AdrPostcode>	

Referral details – Use a separate copy of the referral form or each type of service	
Eligible patients may access Medicare rebates for up to 5 allied health services (in total) in a calendar year. 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	

Aboriginal Health Worker	
81300	

Audiologist	
81310	

Chiropractor	
81345	

Diabetes Educator	
81305	

Dietitian	
81320	

	
No of services	
AHP Type	
Item Number	

Exercise Physiologist	
81315	

Mental Health Worker	
81325	

Occupational Therapist	
81330	

Osteopath	
81350	

Physiotherapist	
81335	

	

	No of services	
AHP Type	
Item Number	

Podiatrist	
81340	

Psychologist	
81355	

Speech Pathologist	
81360	

	
Referring GP’s signature

	Date signed
<Date>	
		
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	
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.	
This form contains all the components of the original referral form developed by the Department of Health and Ageing and therefore meets the Department's requirements.
The original version of this form may be downloaded from the Department of Health and Ageing website at www.health.gov.au/mbsprimarycareitems	
THIS FORM DOES NOT HAVE TO ACCOMPANY MEDICARE CLAIMS