Patient Referral Form

Advanced Exercise Physiology
ABN: 91626984816
Lvl 4, 9/12 Miller St Merrylands, Sydney
NSW 2160
T: 1300 238 237 F: 02 8088 7759
E: info@advancedep.com.au
W: www.advancedep.com.au

Exercise Physiology Referral Form

This referral form is for GP's, Specialists, Rehab Consultants, Support Coordinators, Plan Managers and other key personnel in a case. It provides us with in depth information on a client/patient so that we can effectively implement our services.

Patient/Client Details

Date of Birth *

Patient First Name *

Middle Name

Last Name *

Contact/Mobile Number *

Email Address

Address

Street address

City

State

Postcode

Referral Details

Referral Type *Your patient may require two or more of these referral types. If this is the case, please select the most relevant at this time and leave a note for us in the "extra notes" box at the end of the form.

Insurance Company *

Insurance Claim Number *

Date of Injury *

Case Manager Name

Case Manager Contact Number

Case Managers Email

Is there a Rehab Consultant on the case?

Yes No

Rehab Consultant Name

Rehab Consultant Contact Number

Rehab Consultant Email

Injury DetailsWhat is the injury? Please add any known details or history relating to the case

Is there a GP referral form for Exercise Physiology Services?

YesNo

Has there been a referral form completed which has/will be sent to the insurer?

! We will need a referral form for this patient to attend under the WC/CTP Scheme.

The insurer will need to approve an initial appointment. Please continue with this form and when a referral letter is provided to the parties involved, we can follow up on an approval.

Referral Form Attachment

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Please attach the form in this space. We can follow this up If it has already been sent to the insurer or rehab provider. You can attach multiple documents

Supporting Documents

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Please attach documents/reports such as a certificates of capacity in this space (if any) or the patient can bring it with them when an appointment is made. You can attach multiple documents

NDIS Plan Number *

NDIS Plan Expiry Date

Guardian NamePlease list the guardian name and relation to the participant

Guardian Contact Number

Disability *Please list the reason why this participant is on the NDIS

How is the NDIS Plan managed?

Self- ManagedPlan ManagedNDIA Managed

! We are currently working with plan managed and self- managed participants at this time.

Please continue with this form. We will contact you to discuss other options.

Plan Manager Company Name

Plan Manager Email

Plan Manager Contact Number

Is there an NDIS Support Coordinator

YesNo

Support Coordinator Name

Support Coordinator Email

Support Coordinator Contact Number

Which item code(s) is this participant expecting to use?

15_200_0126_1_3, Improved Daily Living (Assessment Recommendation Therapy or Training - Exercise Physiologist)12_027_0126_3_3, Improved Health and Wellbeing (Advice provided by an Exercise Physiologist regarding exercise required)01_741_0128_1_3, Therapy Supports and Early Childhood Supports (Assessment Recommendation Therapy or Training Supports - Other Professional)

Medicare Card Number *

Medicare Card Expiry Date *

IRNPatient number next to their name on the card

Medical Condition/ Referral Reason

Is there a GP Medicare referral form for Exercise Physiology Services?

YesNo

Has there been an EPC/CDM/group diabetes referral form completed?

! We will need an EPC referral form for this patient to attend using Medicare.

Please continue with this form, your patient can bring this in with them to their appointment.

Attach Referral and Medical History

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Please attach the referral and medical history forms in this space. Alternatively, your patient can bring this with them to their appointment.

Private Health Company

Private Health Customer Number

Private Health ID Number

! We recommend the patient check their policy to see if Exercise Physiology is covered

CommentsPlease add any comments you might have regarding the reason for attending our services

DVA Card Type *

White CardOrange CardGold Card

Condition/Disability *

DVA Card Number *

DVA Card Expiry Date *

Attach DVA D904 Referral Form

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Please attach the D940 referral form in this space or the card holder can bring it with them

Patient Management Plan

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If applicable, please attach the patient management plan or the card holder can bring it with them

Comments on the Condition/DisabilityPlease add any comments you might have regarding the reason for attending our services

Can we have some more information?Please give us some information regarding the reason for attending our services

Extra NotesFeel free to give us any more information regarding the reason for attending our services

Referrer Name

Your Position

Phone

Email

Organisation

Do you give us consent to collect and store the information provided? Terms and Conditions *

Save and Complete Later