Referral date:   	<TodaysDate>	
PROVIDER DETAILS	
GP Name	<DrName>	
Provider Number	<DrProviderNo>	
Practice Name	<DrProviderNo>	
Practice Phone	<LocationName>	
Practice Fax	<LocationFax>	
Alternate GP	<Is there an alternate GP for this patient? If so please provide their name:>	
PATIENT DETAILS	
Name	<PtFullName>	
Dated of Birth	<PtDoB> (<PtAge>)	
Medicare Card	<PtMCNo> (<PtMCLine>) | <PtMCExpiry>	
Health Care Card	<PtOccupation>	
Address	<PtAddress>	
Phone	H: <PtPhoneH> M: <PtPhoneMob>	
Sex | Gender	<PtSex> | <GenderIdentity>	
Ethnicity	<PtEthnicity>	
Preferred Language	<Language spoken at home?>	
Interpreter required:	<Does the patient require an interpreter?>	
FAMILY AND SOCIAL HISTORY	
Does the patient work?	<PtOccupation>	
Does the patient have a partner?	<Does the patient have a partner?>	
If yes, partners full name:	<If yes, partners full name:>	
Does the patient have a carer?	<Does the patient have a carer?>	
If yes, carers full name:	<If yes, carers full name:>	
If yes, is the carer related?	<If yes, is the carer related?>	
Partner/Carers contact phone number/s:	<Partner/Carers contact phone number/s:>	
Patient consents to referral:	<Patient consents to referral?>	
Consent to contact partner / carer?	<Consent to contact partner / carer?>	
REFERRAL DETAILS	
Reason for referral:	<Reason for Referral?>	
Current Chronic Disease Management	<Select all that apply: Include selected documents with referral>

Note: Please attach a copy of the relevant care plan/s to this form.	
The patient is considered to have limited access to multidisciplinary care from allied and other health professionals due to: (Please tick all that apply)
	<The patient is considered to have limited access to multidisciplinary care from allied and other health professionals due to: (Please tick all that apply)>	
Supporting Comments:
	<Supporting Comments:>	
MEDICAL HISTORY	
History:
<SelectedPMH>	
Medications
<SelectedRx>	
Allergies:
<Reactions>	
Immunisations:
<Imm>	
PATIENT COHORT	
People with Chronic conditions and complex care needs – items 10950 to 10970​	
ELIGIBILITY CRITERIA	
Selection Criteria
•	Community based​
•	Have a chronic medical condition and complex care needs​
•	Have a GP management Plan (GPMP – item 721 or 715)
•	Have an Aboriginal and Torres Strait Islander Peoples Health Assessment (item 715) 
•	​Eligible for a Team Care Arrangements (TCA – item 723)​
•	Aged 18 and over, or 15 and over for Aboriginal and Torres Strait Islander (ATSI)​
•	Consented to referral​	
Exclusion Criteria​:
•	Permanent residents of RACF​
•	Medicare ineligible ​
•	DVA Cardholders​
•	NDIS clients	
GUIDE TO COMPETING THIS REFERRAL FORM	
*The patient must give consent to be contacted by the Chronic Care Coordination program
1.	Please complete all sections of this form and return to Silver Chain Group via Healthlink EDI: virginia
2.	Please tick all that apply to patient
3.	All sections are mandatory fields
4.	For enquiries, please phone 1300 650 803	
TIPS TO COMPLETE THIS REFERRAL FORM	
•	Ensure the patient has a handout explaining the Chronic Care Coordination program 
•	Ensure that the patient has access to a telephone by including all phone numbers in patient details section 
•	Need to ensure a copy of the relevant care plan/s to this form:
o	GP Management Plan (GPMP item 721 / review item 732) AND
o	Aboriginal and Torres Strait Islander Peoples Health Assessment (item 715) 
o	Team Care Arrangements (item 723 / review item 732) OR 
o	Mental Health Treatment Plan  (item 2700, 2701, 2715 or 2717 / review item 2712 or 2713)
•	Need to ensure a medical summary is included in the Additional information section or as an attachment 
•	Please advise in the supporting comments section if the patient is involved in the following programs:
o	Social prescribing
o	ITC 
o	Pharmacy support 
•	Please advise in the supporting comments section if the patient is involved with:
o	Specialist care service
o	Palliative Care
o	Oncology 	
FURTHER INFORMATION	
For all general enquires please contact Ph: 1300 650 803 or email: southeastnsw_carecoordination@silverchain.org.au
Silver Chain Group: https://silverchain.org.au/
COORDINARE South Eastern Primary Health Network (link: to be added)
Health Pathways link: https://www.coordinare.org.au/for-health-professionals/system-integration/healthpathways/	
RELEVANT INVESTIGATIONS	
<Ix>