Referral form for Allied Health Group Services under Medicare
 for patients with type 2 diabetes	
PART A – To be completed by referring GP (tick relevant boxes):	
	Patient has type 2 diabetes  AND either 	
	GP has prepared a new GP Management Plan (MBS item 721) OR

	
	GP has reviewed an existing GP Management Plan (MBS item 725) OR
	
   for a resident of an aged care facility, GP has contributed to or reviewed a care plan prepared by the facility (MBS item 731) [Note: Generally, residents of an aged care facility rely on the facility for assistance to manage their type 2 diabetes. Therefore, residents may not need to be referred for allied health group services as the self management approach may not be appropriate.]
Note: GPs are encouraged to attach a copy of the relevant part of the patient’s care plan to this form.	
Please advise patients that Medicare rebates and Private Health Insurance benefits cannot both be claimed for this service
	
GP details	
Provider Number	 		 		 		 		 		 		 		 									
																								
Name	     			
			
Address	     	Postcode      		
Patient details	
First Name	     		Surname	     		
						
Address	     	Postcode      		
Note: Eligible patients may access Medicare rebates for one assessment for group services item in a calendar year.  Indicate the name of the practitioner (diabetes educator, exercise physiologist or dietitian), or the allied health practice, you wish to refer the patient to for this assessment.  The assessment must be done before the patient can access group services. 	
Allied Health Practitioner (or practice) the patient is referred to for Assessment: 	
Name of AHP or practice	Katerina Zirogiannis REHABILITATION IN MOTION EXERCISE PHYSIOLOGY		
					
Address	Suite 6, 25 Victoria St, WOLLONGONG NSW	Postcode  2500		

					
Referring GP’s signature					
		Date		

					
PART B – To be completed by Allied Health Professional who undertakes Assessment service:
Eligible patients may access Medicare rebates for up to 8 allied health group services in a calendar year. Group size must be between 2 and 12 persons.  
Indicate the name of the provider/s, and details of the group service program.  

Rehabilitation in Motion:  Katerina Zirogiannis, Exercise Physiologist

Name of provider/s:                       

Rehabilitation in Motion- 8 week type 2 diabetes group exercise program

Name of program: 

8

No. of sessions in the program: 

Rehabilitation in Motion, Suite 6, 25 Victoria St, WOLLONGONG NSW 2500

Venue (if known):

Name of Referring AHP:                                                                                Signature  
                                                                                                                         and date	
AHPs must provide, or contribute to, a written report to the patient’s GP after the Assessment service and at completion of the group services program.
AHPs should retain a copy of the 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
these items, except where the service is operating under sub-section 19(2) arrangements.
This form may be downloaded from the Department of Health and Ageing website at www.health.gov.au/epc
or ordered by phoning (02) 6289 4297 or faxing (02) 6289 7120.	
THIS FORM DOES NOT HAVE TO ACCOMPANY MEDICARE CLAIMS