Referral form for Allied Health Group Services under Medicare for patients with type 2 diabetes

PART A - To be completed by referring GP
¨  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 725) OR
¨  For a resident of an aged care facility, GP has contributed to or reviewed a care plan prepared by the facility (MBS item 731) [Note: Generally residents of an aged care facility 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 benefit cannot both be claimed for this service.	
GP details:
Provider Number: <DrProviderNo>
Name: <DrName>
Address: <DrStreet>, <DrCity> <DrState> <DrPostcode>	
Patient details:
Name: <PtName>
Address: <PtStreet>, <PtCity> <PtState> <PtPostcode>
Note: eligible patients may access Medicare rebates for one assessment for group services item 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 the group services.	
Allied health practitioner (or practice) the patient is referred to for Assessment:
Name of AHP or practice: <AdrName>
Address: <AdrAddress1>, <AdrCity> <AdrState> <AdrPostcode>	
Referring GPs signature:		  Date: <Date>	
Part B - to be completed by Allied health Professional who undertakes assessment service
Eligible patients may access Medicare rebates for up to 8 allied health group services in a calendar year. Group sizes must be between 2 and 12 persons.
Indicate the name of the provider/s, and details of the group service program.	
Name of provider/s:		
Name of program:		
No. sessions in the program:		
Venue (if known):		
Name of referring AHP:
		Signature 
and Date		
	
AHPs must provide, or contribute to, a written report to the patient’s GP after the Assessment service and at completion of the group services program.

AHPs should retain a copy of the referral form for record keeping and Medicare Australia audit purposes.

Allied health services funded by other Commonwealth or State/Territory programs are not eligible for Medicare rebates under these items, except where the service is operating under sub-section 19(2) arrangements.	
THIS FORM DOES NOT HAVE TO ACCOMPANY MEDICARE CLAIMS