Referral date:   	<<Miscellaneous:Date>>	
PROVIDER DETAILS	
GP Name	<<Doctor:Name>>	
Provider Number	<<Doctor:Provider Number>>	
Practice Name	<<Practice/Location:Name>>	
Practice Phone	<<Practice/Location:Phone>>	
Practice Fax	<<Practice/Location:Fax>>	
Alternate GP	<<If you are not the patient's main GP please name:>>	
PATIENT DETAILS	
Name	<<Patient Demographics:Full Name>>	
Dated of Birth	<<Patient Demographics:DOB>> (<<Patient Demographics:Age>>)	
Medicare Card	<<Patient Demographics:Medicare Number>> | <<Patient Demographics:Medicare Expiry Date>>	
Health Care Card	<<Patient Demographics:Health Insurance>>	
Address	<<Patient Demographics:Full Address>>	
Phone	H: <<Patient Demographics:Phone (Home)>>M: <<Patient Demographics:Phone (Mobile)>>	
Sex | Identifies as Transgender	 <<Patient Demographics:Gender>> | <<Patient Demographics:Transgender>>	
Ethnicity	<<Patient Demographics:Ethnicity>>	
Preferred Language	<<Patient Demographics:Language Preferred>>	
Interpreter required:	<<Patient Demographics:Requires Interpreter>>	
FAMILY AND SOCIAL HISTORY	
Does the patient work?	<<Patient Demographics:Occupation>>	
Does the patient have a partner?	<<Patient Demographics:Marital Status>>	
If yes, partners full name:	<<Patient Partners name: >>	
Does the patient have a carer?	<<Does the patient have a carer?>>	
If yes, carers full name:	<<If yes, what is the carers name?>>	
If yes, is the carer related?	<<If yes, what is the carers relationship to the patient?>>	
Partner/Carers contact phone number/s:	<<If yes, Partner/Carers contact phone number:>>	
Patient consents to referral:	<<Patient consents to referral?>>	
Consent to contact partner / carer?	<<Consent provided to contact partner / carer?>>	
REFERRAL DETAILS	
Reason for referral:	<<Reason for Referral: >>	
Current Chronic Disease Management	<<Select all that apply: Include selected documents >>

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)
	<<Related issues: Select all that apply:>>	
Supporting Comments:
	<<Supporting \ Other Comments?>>	
MEDICAL HISTORY	
History:
<<Clinical Details:History List>>	
Medications
<<Clinical Details:Medication List>>	
Allergies:
<<Clinical Details:Allergies/Adverse Reactions>>	
Immunisations:
<<Clinical Details:Immunisation List>>	
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:
•	GP Management Plan (GPMP item 721 / review item 732) AND
•	Aboriginal and Torres Strait Islander Peoples Health Assessment (item 715) 
•	Team Care Arrangements (item 723 / review item 732) OR 
•	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:
•	Social prescribing
•	ITC 
•	Pharmacy support 
•	Please advise in the supporting comments section if the patient is involved with:
•	Specialist care service
•	Palliative Care
•	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	
<<Summary:Investigation Results (Selected)>>