Medicare Online Referral Form | Allied Health Access

PATIENT DETAILS

Select *

Preferred Name *

Full Name *

Date of birth *

Gender *

Phone *

Address *

Email *

Medicare number *

Reference number *

Expiry Date *

ADVOCATE AND GUARDIAN INFORMATION

Organisation *

Full Name *

Phone *

Email *

Address *

Are the Medicare details for the parent the same as those for the patient? *YesNo

Medicare number *

Reference Number *

Expiry Number *

REFERRING GP CONTACT DETAILS

Please Note: The GP Provider number is required for claiming - this can be found on your health care plan.

Organisation *

Full Name *

Phone *

Fax *

Email *

GP Provider Number *

Address *

SERVICES REQUIRED

Services *Medicare better access: Individual therapy (Psychology)Medicare EDPT (Eating Disorder Psychological Treatment)Medicare Chronic Disease Management Plan: Individual consults with a dietitian.Medicare Allied Health Services*Please note: GP Mental Health Treatment Plan required.

INITIAL APPOINTMENT

Appointment preferencesPreferred timeNo preference

Day *MondayTuesdayWednesdayThursdayFridayORS will try and ensure we meet your preferences where we can. However, some times are particularly popular, such as after school hours for children, which may make it harder to organise at these times. In these cases, we will be in touch to discuss options (e.g., appointments at school etc.).

Appointment Comments

DOCUMENTATION

Please provide a copy of the medical care plan and general practitioner referral letter. If you do not yet have a medical care plan, please visit your general practitioner to have this completed. This plan is required to be completed before your first appointment so that you can access the Medicare rebates. File Upload * *

No file chosen

FURTHER INFORMATION

Relevant Information not previously mentioned