Integrated Care Coordination (ICC) or Integrated Team Care (ITC)
Phone: 	(02) 6937 2000 
Fax: 	(02) 6323 1874
Email: 	ic.intake@marathonhealth.com.au 
Please select the appropriate program (ICC Program/ ITC Program (GPMP required):
<ICC or ITC?>   
Referral Date	<TodaysDate>	Next of Kin (NOK)	<NOKName>	
Client’s Name	<PtFullName>	NOK Phone	<NOKContact>	
Date of Birth	<PtDoB>	NOK Relationship	<NOKRelation>	
Phone	<PtPhoneMob> <PtPhoneH>	Carer’s Name 	<CntName>	
Address 
	<PtAddress>	Carer’s Phone Number	<CntPhone>	
Medicare No	<PtMCNo>	Medicare Exp	<PtMCExpiry>	
Pension Card	<PtPensionNo>			

Aboriginal 	<PtEthnicity>	Smoker	<SmkStatus> <SmkHx>	
Torres Strait Islander	<PtEthnicity>	Current GPMP	<Current GPMP>	
Aboriginal and Torres Strait	<PtEthnicity>			

Referred by (GP/LHD/Self/Other):	<Referred by?>	
GP Name 	<DrName>	
Phone 	<DrPhone>	
Address 	<DrAddress>	

Reason for referral
<Reason for Referral>	

Medical history
<PMHActive>	

Has the client been diagnosed with any of the following conditions (Diabetes/ Chronic Kidney Disease/ Cardiovascular Disease/ Chronic Respiratory Disease/ Cancer/ Parkinson’s Disease/ Risk of Unplanned Admission):
<Diagnosed with>	
Additional information: 
<Additional info on diagnosis>

Other relevant medical history
<PMHAll>

Relevant admission history
 <Relevant admission history>

Client Consent provided	<Client Consent provided?>	
Current GPMP / TCA
GPMP required for ITC program. 
(please attach with referral)	<Current GPMP/TCA client?>	
715 Health Check (if available)	<715 Health Check client?>