GP Management Plan and Team Care Arrangements

Patients Details:	<<Patient Demographics:Full Name>>	DOB: 	<<Patient Demographics:DOB>>	
Name & Contact Details of Carer (if applicable):	 	
GP Details:	<<Doctor:Name>>
<<Doctor:Full Address>>
Ph: <<Doctor:Phone>>   Fax: <<Doctor:Fax>>	

PATIENT CONSENT TO PROCEED: 
The patient has had explained the steps and costs involved and has agreed to proceed with the service. 
If proceeding with Team Care Arrangements the patient has also agreed to the involvement of other health providers and to share clinical information without / with specific medical or other information to be withheld from other participants (as noted in GPs records).	
Signature:                                                                                   Date:	

Multidisciplinary Team Care Arrangements (if relevant)
SERVICE PROVIDER	CONTACT DETAILS	AGREEMENT TO BE INVOLVED (DATE/METHOD)	COPY OF CARE PLAN
(Y/N)	ADDITIONAL COMMENTS	

					

GP Management Plan and Team Care Arrangements

Patients Name:	<<Patient Demographics:Full Name>>	DOB:	<<Patient Demographics:DOB>>	

PATIENT PROBLEMS, 
NEEDS & CONDITIONS	GOALS 
(Changes to be achieved)	REQUIRED TREATMENT & SERVICES including PATIENT ACTIONS	PROVIDER - Arrangements for treatments/services	REVIEW	

					

					

					

					

					

					

Copy of Plan offered to Patient:   YES  /  NO	Copy of Plan added to Patient Records:   YES  /  NO	

PLAN REVIEW DATE: (Review ³ 3 monthly intervals) 					

MBS Item(s):
& Date Service Completed	GP Management Plan: Item 721- 

Team Care Arrangements: Item 723 -	Review of GPMP: Item 725 -

Review of TCAs: Item 727 - 	

RELEVANT MEDICAL CONDITIONS/DIAGNOSIS
<<Clinical Details:History List>>

CURRENT MEDICATIONS
<<Clinical Details:Medication List>>

ALLERGIES
<<Clinical Details:Allergies>>

IMMUNISATIONS
<<Clinical Details:Immunisation List>>