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GP Referral Forms & Templates - All Program Areas

Aged Care	Lifestyle Modification Program	Sutherland Hospital Access & Referral Intake

Chronic Disease Management	Mental Health Assesment Plan & Review	Multidisciplinary High Risk Foot Clinic

GP Exercise Referral	ATAPS Program	Lifescripts (Smoking, Nutrition, Alcohol & Physical Activity)

45 year old health checks	Womens Health - SANC	Preventative Health Checks - Aboriginal & Torres Strait Islander

Aged Care Templates	Manual version	BP/MD Electronic templates
Common Admission to RACF Form	PDF (51KB )	None
Medical Assessment of CMA (page 4) MD (Medical Director) Template	None	RTF (18.3KB)
Residential Medication Management Reviews GP Referral Form	PDF (36.4KB)	RTF (28KB )
Residential Medication Management Reviews Management Template	PDF (30.4KB)	RTF (19KB)
Contribution to Care Plan (ITEM 731)	PDF (30KB)	RTF (19KB)
Referral to Allied Health Provider under Medicare (to be completed by the GP)	PDF (89KB)	RTF (310KB)
Case Conference Items (734-738 and 775-779)	PDF (32KB)	RTF (27KB)
Transfer of Medical Care Form Template	PDF (38KB)	RTF (37KB)
RACF Transfer to Hospital Form - Nursing	PDF (332KB)	None
RACF & SESIAHS Aged Care Discharge Summary Form	PDF (29KB)	None

CDM Templates	Manual version	BP/MD Electronic templates
Refusal Letter to Allied Health Professionals initiating Team Care Arrangement	None	RTF (15KB)
"Reverse Referral" Allied Health Professionals initiating Team Care Arrangement	None	RTF (4KB)
or providing part-completed referral forms to GPs for signature, pre-empting GP's decision
Generic Referral Template (developed by Monash Division of General Practice)	Word (37KB)	RTF (18KB)
GP Preparation of GP Management Plan (721) and Team Care Arrangement (723)	Word (55KB)	RTF (24KB)
GP Preparation of a GP Management Plan for Diabetic Patients	Word (87KB)	RTF (24KB)
GP Review (725 and 727) GP Management Plan and Team Care Arrangement	Word (50KB)	RTF (20KB)
GP Cover Letter Team Care Arrangement to Allied Health Professionals	None	RTF (6KB)
RACGP - Care Planning Templates. These are disease specific templates for GP Management Plans and Team Care Arrangements	None	CLICK HERE
Allied Health Referral Form Medicare Australia	PDF (89KB)	RTF (212 KB)

GP Exercise Referral Scheme (GPERS) Templates	Manual version	BP/MD Electronic templates
GPERS Referral Template to the Leisure Centres (Sutherland/Engadine)	PDF (127KB)	RTF (39KB)
Referral Agreement Process (RAP Form)	PDF (188KB)

Get Healthy Coaching Service Referral Templates	Manual version	BP/MD Electronic templates
GP Referral Form to the Get Health Coaching Service Medical Director Template	None	RTF (366 KB)
GP Referral Form to the Get Health Coaching Service Best Practice Template	None	RTF (366 KB)

45 Year Old Health Check Templates	Manual version	BP/MD Electronic template
45 Year Old Health Check Template	Word (68KB)	RTF (38KB)
Patient Recall Letter Generic Template	Word (30KB)	RTF (9KB)
Patient Recall Letter 'at risk' recall Template	Word (29KB)	RTF (7KB)

Lifestyle Modification Program (LMP)	Manual version	BP/MD Electronic templates
GP Referral Form - Medical Director Template	PDF (194KB)	RTF (31KB)

Mental Health Plan and Review Referral Templates	Manual version	BP/MD Electronic templates
GP Mental Health Care Plan - Assessment Template	Word (54KB)	RTF (42KB)
GP Mental Health Care Plan - Plan and Review Template	Word (48KB)	RTF (34KB)
Combined GP Mental Health Care Plan - Assessment, Plan and Review Template	Word (89KB)	RTF (81KB)
Combined GP Mental Health Care Plan - Assessment, Plan and Review Best Practice Template		RTF (81KB)

ATAPS Program Templates	Manual version	BP/MD Electronic templates
GP Mental Health Care Plan - Assessment Template	Word (54KB)	RTF (42KB)
GP Mental Health Care Plan - Plan and Review Template	Word (48KB)	RTF (34KB)
Combined GP Mental Health Care Plan - Assessment, Plan and Review Template	Word (89KB)	RTF (81KB)
Combined GP Mental Health Care Plan - Assessment, Plan and Review Best Practice Template	Word (89KB)	RTF (81KB)
Fax coversheet	Word (2KB)	None

Mental Health - Sutherland Hospital & Community Health Service	Manual version	BP/MD Electronic templates
Central Network Intake Service (ACCESS Team) Referral Form	Word (80KB)	None
Child Youth and Family Referral Form, Sutherland Hospital and Community Health Service	PDF (92 KB )	None

Antenatal Referral Forms for all GPs	Manual version	BP/MD Electronic templates
Combined Sutherland and St George Hospitals Antenatal Referral Form	PDF(103KB)	RTF (52KB)
Royal Hospital for Women Antenatal Referral Form	PDF (96KB)	None

Antenatal Shared Care Templates for GPs who are registered with the program	Manual version	BP/MD Electronic templates
Letter (sample) from GP to ANCP - Patient needs to be assessed for SANC	Word (26KB)	None
Letter (sample) from GP to Patient - Missed appointment	PDF (86KB)	None

Common Referral Form for Sutherland, Calvary and St George Community Services Access and Referral Intake Form	Manual version	BP/MD Electronic templates
Access and Referral Intake Form	Word (68KB)	RTF (33KB)

Central Hospitals Network Multidisciplinary High Risk Foot Clinic	Manual version	BP/MD Electronic templates
GP Referral Form to Central Hospitals Network Multidisciplinary High Risk Foot Clinic	PDF (73KB)	None

Aboriginal and Torres Strait Islander Health Check	Manual	BP/MD Electronic templates
GP Referral Form- Health Assessment Aboriginal & Torres Strait Islander people - Manual/pdf Template	PDF (143KB)
GP Referral Form - Health Assessment Aboriginal & Torres Strait Islander people - Best Practice & MD Template	see above	RTF (105KB)
GP Referral Form - Child Health Checks - Best Practice & MD Template	see above	RTF (1033KB)
GP Referral Form - Adult Health Checks - Best Practice & MD Template	see above	RTF (934KB)
GP Referral Form - Older Persons Health Checks - Best Practice & MD Template	see above	RTF (846KB)
Template - Aboriginal & Torres Strait Islander Health Check - Adult	see above	RTF (104KB)
Template - Aboriginal & Torres Strait Islander Health Check - Child	see above	RTF (105KB)
Template - Aboriginal & Torres Strait Islander Health Check - Older Person	see above	RTF (109KB)