Title: Referral Care Coordination and Supplementary Services

REFERRAL: Care Coordination and Supplementary Services

Attention:  	 CCSS Care Coordinator 

Regarding: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>     DOB: <<Patient Demographics:DOB>>   
			
Medicare No: <<Patient Demographics:Medicare Number>>                              Phone number: <<Patient Demographics:Phone (Home)>>

Service required:
•	Care Coordination and Supplementary Services

Patient eligibility (please note, each point is required for patient to be considered eligible):

•	Completed GPMP (MBS 721 and/or TCA (MBS 723) - please attach to referral
•	Patient has at least one of the following 5 chronic conditions which has been, or is likely to be, present for six months or longer (please select appropriate condition/s below):
•	Diabetes
•	Cardiovascular Disease
•	Chronic Respiratory Disease
•	Chronic Kidney Disease
•	Cancer

•	

Referring Doctor: ___________________________________________

Signature: ____________________________   Date: ______________

Patient Consent (must be signed at the time of referral)
I understand that personal information regarding the reason for my referral and subsequent services, may be shared with other care providers. This includes other health professionals and also relevant service providers.
Any information held is strictly confidential. I give permission for these care providers to access this information solely for the purpose of this referral. 

Patient signature ____________________________________________ Date _______________

Please fax referral, along with completed GPMP and/or TCA to appropriate Murrumbidgee Medicare Local office. 

Wagga: (02) 6923 3144  -  Leeton: (02) 6953 6653
Lake Cargelligo: (02) 6898 2145  -  Harden: (02) 6385 3538