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

Self Referral Form

This referral form is for you to give us some insight on the types of services you need. 

Your Details

You do not need to provide us with your address at this point in time. We will request this if we schedule an appointment later.

Referral Details

You 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.

If you select "Yes" you will have the opportunity to provide us specific details about your health and case details. None of the sections are mandatory at this point in time.  

If you're not comfortable providing any more information, please select "No" and we will contact you to talk about the next steps.

What is the injury? Please add any known details or history relating to the case
Has there been a referral form completed which has/will be sent to the insurer?

! We will need a referral form for you 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. 

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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
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Please attach documents/reports such as a certificates of capacity in this space (if any) or you can bring it in with you when an appointment is made. You can attach multiple documents
Please list the guardian name and relation to the participant
Please list the reason why you are on the NDIS
Patient number next to their name on the card
What is the reason you're seeing us through Medicare?
Has there been an EPC/CDM or group diabetes referral form completed?

! We will need an EPC referral form for you attend using Medicare.

Please continue with this form, you can bring this in later

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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.

! We recommend you check your policy to see if Exercise Physiology is covered

Please add any comments you might have regarding the reason for attending our services
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Please attach the D940 referral form in this space or you can bring it in with you
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If applicable, please attach the patient management plan or you can bring it in with you
Please add any comments you might have regarding the reason for attending our services
Feel free to give us any more information regarding the reason for attending our services

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