SETAC Primary Health Care & Well-being Centre
7393 Channel Hwy, PO BOX 177, Cygnet Tas 7112
Phone: (03) 6295 1125	Fax: (03) 6295 0752 

Integrated Team Care (ITC) Referral	

Patient Details								Referral Date: <<Miscellaneous:Date>>

Name: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>	Date of Birth: <<Patient Demographics:DOB>>	
Residential Address: <<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>	Post code: <<Patient Demographics:Postcode>>	
Home Phone: <<Patient Demographics:Phone (Home)>>	Mobile: <<Patient Demographics:Phone (Mobile)>>	

Eligibility

Patient fulfils these criteria (please x)
	Has Aboriginal and/or Torres Strait Islander ancestry	

	Identifies as Aboriginal and/or Torres Strait Islander	

	Is known as such in the community in which they live or formerly lived	

Patient has one or more of the following chronic diseases (x all that apply)
	Cancer	

	Cardiovascular	

	Diabetes	

	Renal	

	Respiratory	

	Asthma	

	Other (please list) 	

	Patient has given consent to participate in this program	

	Patient has an up-to-date Care Plan (721) and this is attached 	

Has the patient been registered for the Indigenous Health Incentive PIP?	Yes/ No	
Has the patient had an Aboriginal Health Assessment (715)*	Yes/ No	
 *Please attach, along with medication summary and any other relevant health information	

Please select which service this patient would be more appropriate for (if known):
	Care Coordinator			Supplementary Service	

Can assist Aboriginal and/or Torres Strait Islander patients to:
Understand their diagnosis
•	Understand and follow their care/management plans
•	Arrange appointments for diagnostic tests, allied health professionals, or specialists
•	Connect with other community-based services
Assist patients to develop self-management skills and adhere to medication and treatment regime		Funds can, at times, assist your Aboriginal and/or Torres Strait Islander patients with:
Transport support to attend appointments
•	Access of private specialist/health professional if public is not available, or waiting list is inappropriate for patient’s condition
•	Payment of gap or full fee (where MBS rebate is not available) for specialist or allied health follow-up care

GP Details

GP Name: <<Doctor:Name>>	
Address: <<Doctor:Address Line 1>>, <<Doctor:City>>	Post code: <<Doctor:Postcode>>	
Phone: <<Doctor:Phone>>	Fax: <<Doctor:Fax>>	

Signature: ................................................... (Referring GP)       Date: <<Miscellaneous:Date>>
Note: Contact cannot be made with patient until a referral form has been received and processed

Please fax completed referral and supporting documentation to
SETAC Primary Health Care & Well-being Centre on (03) 6295 0752