Empowering Local Health Referral

To Receive Services In Which Region? *

Somerset Region (eg. Lowood, Fernvale, Esk, Toogoolawah)Southern Downs Region (eg. Allora, Warwick, Killarney, Stanthorpe)

Has the patient already been booked in for an appointment? *

Yes (The patient has an existing booking with Healthy Lifestyles Australia staff)No (Please contact this patient to book them in)

PATIENT DETAILS

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

MaleFemaleOther

Culturally and linguistically diverse background? *

YesNo

Aboriginal and/or Torres Strait Islander *

AboriginalTorres Strait IslanderNone of the AbovePrefer Not to Answer

Over 65 years of age? *

YesNo

PATIENT CONTACT DETAILS

Mobile Phone *

Email

Home Phone

Work Phone

Address *

City / Suburb *

State *

Postcode *

Eligibility Criteria Questions

Can the patient access this service through any of the following? *

If you ticked 'None of the above' please continue to the next question. If you answered yes to one of the above options the patient is not eligible to receive services under the Empowering Local Health Program. Alternative referrals can be faxed to (07) 3053 8133.

Chronic Conditions Management Plan

Does the patient have a GP Management Plan? *

Yes (Please attach to this referral if you have it)No

If Yes, are there team care arrangements in place?

Yes (Please attach to this referral)NoN/A

If the patient is on a Medicare Chronic Conditions Management Plan have they had all their Allied Health visits allocated?

YesNo (Client is not eligible for referral under this program until all Allied Health Medicare eligible visits have been allocated)N/A

Please upload GPMP and TCA if available or any other document to inform care

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Eligible Chronic Condition and/or Risk Factor

Type of Service Requested

Please choose service required from the list of professionals available (Tick all that apply) *

Presenting Problem/Diagnosis and Goals

Provide brief description of the person and/or reason/s for referral

Provide brief description of the patient-centred goals/outcomes to be achieved

REFERRING Doctor / Nurse / Health Professional

Referrers Name *

Address *

Referrer Provider Number (If available)

Referrer Phone Number

Signature of Referrer *

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Date of Referral *

Patient Acceptance of PHN Service and Consent to Use Personal Information

I understand that this referral is for a Darling Downs and West Moreton PHN funded service for myself or my dependent.

To receive this service, I consent to specific information being collected and utilised for referral purposes and health service navigation and access. This information is required for the Department of Health to enable ongoing performance evaluation of the service.
Information collected will include information from the initial section of this form, type of service covered by the referral and quantitative measures of service outcomes.
De-identified data may be used for the purposes of program evaluation and data analysis.
Collated data will be de-identified by the Darling Downs and West Moreton PHN commissioned agency prior to analysis and reporting.

I accept the above terms *

Patient / Guardian Signature *

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Today's Date *

Darling Downs and West Moreton PHN and Healthy Lifestyles Australia is committed to providing you with the highest levels of confidentiality and customer service and this includes protecting your privacy. Darling Downs and West Moreton PHN and Healthy Lifestyles Australia are bound by the Commonwealth Privacy Act 1988 and the Privacy Amendment (Private Sector) Act 2000, which set out a number of principles concerning the protection of your personal information.

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