Referral date:   	<TodaysDate>	
PROVIDER DETAILS	
GP Name	<DrName>	
Provider Number	<DrProviderNo>	
Practice Name	<LocationName>	
Practice Phone	<LocationPhone>	
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	Error! Hyperlink reference not valid.	
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	
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>