Referral form for follow-up allied health services under Medicare
for People of Aboriginal or Torres Strait Islander descent

Note: GPs can use this form issued by the Department of Health and Ageing or one that
contains all of the components of this form.	
To be completed by referring GP

Health assessment completed:
701- <<Health Assessment - 701>>        703 -  <<Health Assessment - 703>>       705 - <<Health Assessment - 703>>       707-<<Health Assessment - 707>>         715 - <<Health Assessment - 715>>	

GP details

Provider Number 	
 <<Doctor:Provider Number>>	

	

Name	
<<Doctor:Name>> <<Doctor:Qualifications>>	

	

Address  	
  <<Doctor:Full Address>>	
Postcode  <<Doctor:Postcode>>	

Patient details

Medicare Number 	
 <<Patient Demographics:Medicare Number>>	
Patient's ref/IRN: 	

	

First Name 	
  <<Patient Demographics:First Name>>	
Surname  <<Patient Demographics:Surname>>	

	

Address  	
      <<Patient Demographics:Full Address>>	
Postcode  <<Patient Demographics:Postcode>>	

Allied Health Professional (AHP) patient referred to: (Specify name or type of AHP)

Name 	
<<Addressee:Full Details>>	
<<Addressee:Specialty>>	

	

Address  	
         <<Addressee:Full Address>>	
Postcode  <<Addressee:Postcode>>	

Referral details - Use a separate copy of the referral form for each type of service

Eligible patients may access Medicare rebates for up to 5 allied health services (in total) in a calendar year. Indicate the number of services required by writing the number in the 'No. of services' column next to the relevant AHP.	
No of 
services	
AHP Type	Item 
Number		No of 
services	
AHP Type	Item 
Number		No of 
services	
AHP Type	Item 
Number	
<<Aboriginal Health Worker/ATSI Health Practitioner>>	Aboriginal Health
Worker/Aboriginal and
Torres Strait Islander
Health Practitioner	81300		<<No. of services - Audiologist  81310>>	Exercise Physiologist	81315		<<No. of services - Podiatrist  81340>>	Podiatrist	81340	
<<No. of services - Audiologist  81310>>	Audiologist	81310		<<No. of services - Mental Health Worker  81325>>	Mental Health Worker	81325		<<No. of services - Psychologist  81355>>	Psychologist	81355	
<<No. of services - Chiropractor  81345>>	Chiropractor	81345		<<No. of services - Occupational therapist  81330>>	Occupational Therapist	81330		<<No. of services - Speech Pathologist  81360>>	Speech Pathologist	81360	
<<No. of services - Diabetes Educator 81305>>	Diabetes Educator	81305		<<No. of services - Osteopath  81350>>	Osteopath	81350					
<<No. of services - Dietician 81320>>	Dietician	81320		<<No. of services - Physiotherapist 81335>>	Physiotherapist	81335					

Referring GP's signature	

Date signed  <<Miscellaneous:Date>>	
The AHP must provide a written report to the patient's GP after the first and last service, and more often if clinically necessary.	
Allied health professionals should retain this referral form for record keeping and Medicare Australia audit purposes.	
Medicare rebates and Private Health Insurance benefits cannot both be claimed for these services.
Patients should be advised that they must choose whether to access one or the other.	
This form may be downloaded from the Department of Health and Ageing website at www.health.gov.au/mbsprimarycareitems.	
THIS FORM DOES NOT HAVE TO ACCOMPANY ANY MEDICARE CLAIMS