Care Plan & Referral Template For Individual Allied Health Services Under Medicare

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Care plan & referral template
for Individual Allied Health
Services under Medicare
Preparation & Coordination of:
GP Management Plan [GPMP] (MBS item no. 721)
AND
Team Care Arrangements [TCAs] (MBS item no. 723)
PATIENT DETAILS
Name:
Address:
Phone number:
Date of Birth:
Medicare No.:
Private health insurance details (if applicable):
Details of patient’s carer (if applicable):
DOCTOR PREPARING GPMP & TCA
Dr:
Provider No:
Address:
Phone:
Fax:

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