Care Plan & Referral Template For Individual Allied Health Services Under Medicare Page 4
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4FOR GP USE ONLY:
Copy of GPMP & TCA offered to patient?
YES /
NO
Copy/relevant parts of GPMP & TCA supplied to other providers?
YES /
NO
/ N.A.
Referral forms for Medicare allied health services completed?
YES /
NO
GPMP & TCA added to the patient’s records?
YES /
NO
Review date for this plan: ______________________
Patient’s Agreement:
I have agreed / my carer has agreed to this GP Management Plan & Team Care
Arrangement and I give my consent that my GP may provide a copy of this plan to
other providers involved in my care.
Signed by Patient / Carer / or Verbal: _____________________________________
Date: ____________
Signed by GP: ________________________________________________________
Date: _____________
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