Chronic Disease Management Program (CDMP) GP Referral Form 
Program eligibility:  	
Does this person identify as:  Aboriginal      Torres Strait Islander     Aboriginal & Torres Strait Islander	
The patient has completed a health assessment (MBS 715) in the last 9-12 months 	 Yes 
 Is copy of completed health assessment attached?
	 No – a care plan and health assessment are required for access to this program	
The patient has a current (within previous 6-12 months) GP Management Plan and Team Care Arrangement	 Yes 
 Is a copy of the completed GPMP/TCA attached?		
The patient’s chronic disease type/s (tick one or more as appropriate) 	diabetes     cardiovascular disease      cancer 
chronic respiratory disease  chronic renal disease    
other (please specify) ______________________________	
PIP-IHI Information: 	
This practice is participating in the Practice Incentive Program–Indigenous Health Incentive (PIP-IHI) 	 Yes          No 	
This patient is PIP-IHI registered 	 Yes          No 	
This patient is Closing The Gap (CTG) registered 	 Yes          No 	
  Referring GP details:  	
Name	 	
Phone number 	 	Email  	 	
Practice name  	 	
Practice street address  	 	
Referral date 	_ _ _ / _ _ _ / _ _ _   	
Patient details: 	
Surname 		First Name		
Gender 	 Male      Female 	Date of Birth       _ _ _ / _ _ _ / _ _ _   	
Residential address 		
Phone number 	 	
Patient Observations
(within the last 2 months)

Height:______ Weight: _______ Waist: _______ BMI: _______ BP: _______

  Pulse: ______ HbA1c: ________ ACR: _______ eGFR: _______ 	
The reason my patient requires Care Coordination services (tick 1 or more as appropriate) 
 	•	is at significant risk of experiencing otherwise avoidable (lengthy and/or frequent) hospital admissions 
•	is at risk of inappropriate use of services, such as hospital emergency presentations 
•	is not using community based services appropriately or at all 	

                  Please fax completed form to the NCACCH Chronic Disease Management Program
            on 5335 1272 or scan and email to adminsupport@ncacch.org.au  

Page 1 of 2
	•	needs help to overcome barriers to access services 
•	requires more intensive care coordination than is currently able to be provided by general practice/Indigenous Health Service staff  
•	is unable to manage a mix of multiple community based services 
•	other _________________________________________________________	
Reason patient requires Supplementary Services (i.e. medical specialist/allied health/local transport services in accordance with the care plan (tick 1 or more as appropriate) 	•	to address risk factors, such as a waiting period for a service longer than is    
             clinically appropriate 
•	to reduce the likelihood of a hospital admission 
•	to reduce the patient’s length of stay in hospital 
•	as not available through other funding sources 
•	to ensure access to a clinical service that would not be accessible because
             of the cost of a local transport service 
•	other________________________________________________ 
	
Referral authorised by: 
GP name, signature and stamp 	 	
Date 		_ _ _ / _ _ _ / _ _ _ 	

My GP or Care Coordinator has discussed the Program Fact Sheet with me. I understand what I have been told, any questions I had about the Program have been satisfactorily answered and I now want to participate.  
•	I understand that my participation is voluntary and that I have the right to withdraw from the Program at any time. 
•	I understand that a range of health and community service providers may collect, use and disclose my relevant personal information as part of my care. 
•	I understand that the personal information collected by these organisations will be maintained consistent with National Privacy Principles. It will remain confidential except when it is a legal requirement to disclose information; or where failure to disclose information would place me or another person at risk; or when my written consent has been obtained to release the information to a third party. 
•	I understand that statistical information (that will not identify me) will be collected and used to see how well the Program is working and help improve services for Aboriginal and Torres Strait Islander people. 	
Patient Name and Signature:	Name:                                                   Signature:	
Date: 		_ _ _ / _ _ _ / _ _ _ 	

I have discussed the proposed referral to Care Coordination / Supplementary Service with the patient and am satisfied that the patient understands and is able to provide informed consent to this. 
GP/Care Coordinator name and signature:	Name:                                                     Signature: 	
Date: 	_ __ / _ _ _ / _ _ _ 	

               Please fax completed form to the NCACCH Chronic Disease Management Program
                 on 5335 1272 or scan and email to adminsupport@ncacch.org.au

Page 2 of 2