Insurance/Brokered Services Intake form

Allied Health Brokered Services Referral Form

Client Details

First Name *

Last Name *

Mobile Number

Home Phone Number

Date of Birth *

Address *

Street address *

City *

State *

Postcode *

Include any specifics regarding parking or access

Client's case number/PO number (if applicable)

Client Medical History

Name and Clinic of General Practitioner

Home Visits or In Clinic Visits Required? *

Primary Contact to Arrange Appointments

Name

Phone number

Organisation's Details Providing the Referral

Name of Coordinator/Case Manager *

Organisation *

Phone Number *

Email *

Please select the items payable as part of the brokered service *

AppointmentsTravelReportsCommunication and Handover with Case Coordinator

Number of Appointments Required *

Total Budget Allocation (If Known)

What information do you require in your report? *

I don't need any reportsStandard report delivery from Healthy Lifestyles AustraliaSpecific Report Information (Please include details below or include copy of template)

Specific information required from the report? (Only answer if specific information required)

Services Required

Please indicate the allied health service required. If more than one we will schedule as appropriate.

Select required services

Exercise Physiologist: Initial consultation at clients home/in clinicExercise Physiologist: Review consultation at the clients home/in clinicExercise led sessions: Exercise led/ hydro therapy sessions (after initial consultation)Dietitian: Initial consultation & meal plan at the clients home/in clinicDietitian: Review consultation at the clients home/in clinicDiabetes Educator: Initial consultation at the clients home/in clinicDiabetes Educator: Review consultation at the clients home/in clinicTravel to clients home

Accounts and Billing details

Quote Required? *

YesNo

Email Address for Invoicing/Quoting *

Any specific requirements for invoicing purposes?

Please provided clinical file uploads if helpful to service delivery (Max size 10mb)

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Name of Person Signing

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Date *

After submitting Healthy Lifestyles Australia will review your request and email the required quote for approval. Following approval we will contact the client to organise service delivery. If no quote is required and you have listed the available funding we will commence service delivery. Any questions please contact 07 3088 2323.

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