General Practitioner or Nurse Practitioner details	
Name: <UsrDetails>	Phone: <UsrPhone>	
Practice: <Practice>	Mobile:	
Practice address: <UsrAddress>	Fax: <UsrFax>	
	Email: <PracEmail>	
Patient details	
Name:  <PtFullName>	Home phone:  <PtPhoneH>	
Address: <PtAddress>	Work phone:  <PtPhoneWk>	
	Mobile:   <PtPhoneMob>	
Date of birth:    <PtDoB>                  Age: <PtAge>	Medicare #:   <PtMCNo>            Ref #: <PtMCLine>	
Patient identifies as: <Patient Identifies as: Aboriginal or CALD>	Health Care Card #:	
Referring practitioner, please tick relevant boxes in each section below	
Eligibility - The patient must be diagnosed, or at high risk of, at least one of the three chronic diseases listed, and have limited access to multidisciplinary care due to the following:

<Limited access to multidisciplinary care due to: (select)> 	
		
Chronic disease and comorbidity	
Diabetes:	<Diabetes: (Diagnosed or at high risk of)>	
Cardiovascular:	<Cardiovascular: (Diagnosed or at high risk of)>	
Respiratory:	<Respiratory: (Diagnosed or at high risk of)>	
Current Chronic Disease Management (a copy of the relevant care plan to be attached to this form)
	
<Current Chronic Disease Management: (select)>	
Allied health services recommended:	
<Allied Health Services recommended>	
Reason for referral: (eg change of medication, foot ulcer, recent cardiac event)
<Reason for referral:>

This program aims to improve the health of vulnerable, disadvantaged or otherwise eligible individuals in the Wheatbelt region who are diagnosed or at high risk of chronic diabetes, cardiac or respiratory conditions. Medicare rebates and private health insurance benefits cannot be claimed for these services, however for eligible patients this service is fully funded. The patient gives consent to be contacted by the ICDC Care Coordinator to plan future multidisciplinary care, including telehealth where appropriate.	
Patient’s signature:_____________________________________________	Date: _______________	
Referring practitioner’s signature:__________________________________	Date: _______________	
Send completed form to: Trisha Posiano	Fax: 9621 1532