Referral To: 	Referral Date: <TodaysDate>	
North Western Melbourne PHN
PO Box 139
Parkville, Vic, 3052	Phone: (03) 90884272              Secure Fax: 03 9348 0750                           Email: ccss@nwmphn.org.au	
Patient Details: 	
Surname: <PtSurname>	First Name: <PtFirstName>	
Date of Birth: <PtDoB>	Gender: <PtSex>	
Contact Number(s): (H) <PtPhoneH>
	(m) <PtPhoneMob>	Medicare number: <PtMCNo>	
Residential Address:  	<PtAddress>	
Alternate contact:  	Name:  <Alternate Contact>	Ph:  <Alternate Contact Ph No>	
My patient fulfils all the criteria below 	
o  Is Aboriginal, or Torres Strait Islander, or Aboriginal and Torres Strait Islander 	
o  Has chronic and complex health needs and requires multidisciplinary care 	
o  Has a Care Plan/GP Management Plan. Attach patients care plan with referral 	
o  Has given verbal or written consent to be contacted by the Care Coordinator and to participate in the ITC program   	
Reason for Referral 	

	
Referrer Details 	
GP Name:  <DrName>	Practice Name:  <Practice>	
Phone Number:  <UsrPhone>
GP Provider Number:  <DrProviderNo>	Email:  <DrEmail>	
Practice Address:	<UsrAddress>	
Allocated Care Coordinator:  <Allocated Care Coordinator>	Allocated Outreach Worker:  <Allocated Outreach Worker>	
Patient Information and Consent 	
•	My GP has explained the purpose of this referral for the ITC Aboriginal Health Program
•	I give permission for my medical information to be shared with the care coordinator
•	I understand that all information is held in strict confidence in accordance with our privacy policies	
Patient name and signature:                                                               Date:  <TodaysDate>