Referral To: 	Referral Date: <<Miscellaneous:Date (short)>>	
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: <<Patient Demographics:Surname>>	 First Name: <<Patient Demographics:First Name>>	
Date of Birth: <<Patient Demographics:DOB>>	Gender: <<Patient Demographics:Gender>>	
Contact Number(s): (H) <<Patient Demographics:Phone (Home)>>
	(m) <<Patient Demographics:Phone (Mobile)>>	Medicare number: <<Patient Demographics:Medicare Number>>	
Residential Address:  	<<Patient Demographics:Full Address>>	
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:  <<Doctor:Name>>	Practice Name:  <<Practice:Name>>	
Phone Number:  <<Practice:Phone>>
GP Provider Number:  <<Doctor:Provider Number>>	Email:  <<Doctor:E-mail>>	
Practice Address:	<<Practice:Address>>	
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:  <<Miscellaneous:Date (short)>>