<<Miscellaneous:Practice Letterhead>>

TEAM CARE ARRANGEMENTS - MBS ITEM No. 723 (ASTHMA)

Patient’s Name: <<Patient Demographics:Full Name>> | Date of Birth: <<Patient Demographics:DOB>>

Contact Details: | Medicare or Private Health Insurance Details:

<<Patient Demographics:Full Address>>

<<Patient Demographics:Medicare Number>>
<<Patient Demographics:Health Insurance>>

Details of Patient’s Usual GP: | Details of Patient’s Carer (if applicable):

<<Doctor:Name>>
<<Doctor:Full Address>>

Date of the last Care Plan / Team Care Arrangements (if done):  <<Date of last Care Plan/TCA>>

Other notes or comments relevant to the patient’s Team Care Arrangements: 

PAST MEDICAL HISTORY

FAMILY HISTORY

<<Clinical Details:Family History>>

MEDICATIONS 

<<Clinical Details:Medication List>>

ALLERGIES

Patient’s Name: <<Patient Demographics:Full Name>>

TEAM CARE ARRANGEMENTS  - MBS ITEM No. 723  (ASTHMA)

Goals - changes to be achieved | Required treatments and services including patient actions | Specific arrangements for treatments/services (when, who, and contact details)

Patient to have a clear understanding of asthma and the patient's role in self management.

Patient education

GP
Asthma educator

Optimal asthma management

Development of written asthma action plan.
Regular asthma review.

GP

Achieve and maintain best lung function.  Reduce frequency and severity of asthma attacks

Patient to have regular spirometry to monitor lung function.
Patient to regularly monitor PEFR.

GP

Identify trigger factors

Allergy testing

GP
Allergist

Medication management

Ensure correct use of medications.  Undertake Home Medicine Review

GP
Pharmacist

Smoking cessation

Smoking cessation program

GP 
QUIT program

Maintain physical activity

Development of exercise program suitable to needs of patient

GP
Physiotherapist
Exercise physiologist

Copy of Team Care Arrangements offered to patient?  <<Copy of TCA offered to patient?>>

Team Care Arrangements added to the patient’s records?  <<TCA added to patient record?>>

Copy / relevant parts of the Team Care Arrangements supplied to other providers?  <<Copy of TCA supplied to other providers?>>

Referral forms for Medicare allied health and dental care services completed?  <<Referral forms for Medicare AHPs completed?>>
[For referral forms call 1800 067 307, go to www.hic.gov.au/providers/forms or look under "Supplied" templates] 

Date service was completed:  <<Date service completed>> | Proposed Review Date:  <<Review date (6 months recommended)>>

I have explained the steps and any costs involved, and the patient has agreed to proceed with the Team Care Arrangements.  <<Steps and costs explained, patient agreed>>
The patient also agrees to the involvement of other health providers and to share their clinical information (without / with restrictions).  <<Patient agrees to AHPs and sharing information>>

 GP’s Signature:  ________________________________________________	Date:___________________

Orignal template compiled by Monash Division of General Practice, March 2006