Integrated Care Coordination (ICC) or Integrated Team Care (ITC)
Phone  (02) 6937 2000  Email ic.intake@marathonhealth.com.au  Fax  (02) 6323 1874

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):
<<ITC or ICC?>>
Referral Date | <<Miscellaneous:Date>> | Next of Kin (NOK) | <<Patient Demographics:Next of Kin>>
Client’s Name | <<Patient Demographics:Full Name>> | NOK Phone | <<Patient Demographics:Next of Kin Phone>>
Date of Birth | <<Patient Demographics:DOB>> | NOK Relationship | <<Patient Demographics:Next of Kin Relationship>>
Phone | <<Patient Demographics:Phone (Mobile)>> | Carer’s Name | <<Carer's Name: >>
Address | <<Patient Demographics:Full Address>> | Carer’s Phone | <<Carer's Phone>>
Medicare No | <<Patient Demographics:Medicare Number>> | Medicare Exp | <<Patient Demographics:Medicare Expiry Date>>
Pension Card | <<Patient Demographics:Pension Number>> | |

Aboriginal | <<Patient Demographics:Ethnicity>> | Smoker | <<Clinical Details:Smoking>>
Torres Strait Islander | <<Patient Demographics:Ethnicity>> | Current GPMP | <<Currently on GPMP >>
Aboriginal and Torres Strait | <<Patient Demographics:Ethnicity>> | |

Referred by (GP/LHD/Self/Other): | <<Referred by >>
GP Name | <<Doctor:Name>>
Phone | <<Doctor:Phone>>
Address | <<Doctor:Address>>

Reason for referral
<<Reason for referral>>

Medical history
<<Clinical Details:History List>>

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):
<<Diagnosis>>
Additional information: <<Additional information>>

Other relevant medical history
<<Other relevant medical history>>

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 or TCA>>

715 Health Check (if available) | <<715 Health Check>>

Marathon Health is a not-for-profit, registered charity delivering high quality health and wellbeing services to people wherever they choose to live. This service is supported by funding from the Murrumbidgee Primary Health Network through the Australian Government’s PHN Program.