Referral form for Individual Allied Health Services under Medicare for patients with a chronic medical condition and complex care needs	
Note: GPs can use this form issued by the Department of Health and Ageing or one that contains all of the components of this form.	
To be completed by referring GP:
Please tick:                    Note: GP's are encouraged to attach a copy of the relevant part of the patient's care plan to this form.	
þ	Patient has GP Management Plan (item 721 or review item 732) And Team Care Arrangements (item 723 or review item 732)	
þ	GP has contributed to or reviewed a multidisciplinary care plan prepared by the patient's aged care facility (item 731)	
Medicare rebates and Private Health Insurance benefits cannot both be claimed for these services.Patients should be advised that they must choose whether to access one or the other.	
GP details	
Provider No.	239432ET	
Name	Dr Alison Lyons			
Address	Unit 60, 1 Resort Place
Gnarabup  6285			
Patient details	
Medicare No.	6274715201	
First Name	Debra		Surname	CASSELL		
Address	28 A Lakeview Crescent, Prevelly	  		
Allied Health Professional (AHP) patient referred to: Physiotherapy	
Name	Ms Rebel Ward		
Address	Southern Forest Physiotherapy
Shop3, 5 Pritchard Street
Manjimup  6258	  		
Referral details – Use a separate copy of the referral form for each type of service
Eligible patients may access Medicare rebates for up to 5 allied health services (in total) in a calendar year. Indicate the number of services required by writing the number in the ‘No. of services’ column next to the relevant AHP.  	
	No of services	AHP Type	Item Number		No of services	AHP Type	Item Number		No of services	AHP Type	Item Number		
		Aboriginal Health Worker	10950			Exercise Physiologist	10953			Podiatrist	10962		
		Audiologist	10952			Mental Health Worker	10956			Psychologist	10968		
		Chiropractor	10964			Occupational Therapist	10958			Speech Pathologist	10970		

Diabetes Educator	
10951	

Osteopath	
10966	

	
	
Dietitian	
10954	
	
5	
Physiotherapist	
10960	

				

	

Referring GP’s signature			

Date signed	
18/03/2024	

	
18/03/2024
The AHP must provide a written report to the patient’s GP after the first and last service, and more often if clinically necessary.	
Allied health professionals should retain this referral form for record keeping and Medicare Australia audit purposes.	
Allied health services funded by other Commonwealth or State/Territory programs are not eligible for Medicare rebates under
this initiative.	
This form may be downloaded from the Department of Health and Ageing website at www.health.gov.au/mbsprimarycareitems.	
THIS FORM DOES NOT HAVE TO ACCOMPANY MEDICARE CLAIMS