Referral to myagedcare.gov.au
Fax No: 1800 728 174

Recipient Details:
Client Name: <<Patient Demographics:Full Name>>
Date of Birth: <<Patient Demographics:DOB (long)>>
Gender: <<Patient Demographics:Sex>>
Marital Status: <<Patient Demographics:Marital Status>>
Indigenous/ Cultural Status: <<Patient Demographics:Ethnicity>>
Language spoken at home: <<Patient Demographics:Language Preferred>>

Medicare number: <<Patient Demographics:Medicare Number>>
DVA Number: <<Patient Demographics:DVA Number>>

Support Person: <<Support Person>>
Support Person Phone number: <<Support Perons Ph number >>
Support Person relationship: <<Support person relationship >>

Contact details: 
Address line1: <<Patient Demographics:Address Line 1>>
Address line 2: <<Patient Demographics:Address Line 2>>
Suburb/Town: <<Patient Demographics:City>>
State: <<Patient Demographics:State>>
Postcode: <<Patient Demographics:Postcode>>

Can the client be assessed over the phone:  <<Can the client be assessed over the phone?>>

Phone Number: <<Patient Demographics:Phone (Home)>>
Call back day: <<Call back day preferred>>
Call back time: <<Call back time >>

Referrer Details:
Your Name: <<Doctor:Name>>
Provider Number: <<Doctor:Provider Number>>

Contact Details: 
Address Line 1: <<Doctor:Address Line 1>>
Address line 2: <<Doctor:Address Line 2>>
Suburb/ Town: <<Doctor:City>>
Postcode: <<Doctor:Postcode>>
Phone number: <<Doctor:Phone>>
Email address: <<Doctor:E-mail>>
Relationship to Client: <<Referrer Relationship to Client: >>

Orgainsation Name: <<Practice:Name>>

Referral reason: <<Reason for referral >>
Do you have consent from the client to make this referral: <<Do you have client consent to make referral >>

Further Details: 
<<Further client details relevant to referral >>

Comments/ Recommendation for assessment or services:
<<Comments/ recommendations for service needed>>

Please attach:
- Over 75 Health Assessment 
- Health Summary if not eligible for a Health Assessment.