Referral for Group Allied Health Services Under Medicare for Patients with Type 2 Diabetes
Note: GPs can use this form or one that contains all of the components of this form.

PART A - To be completed by referring GP (Tick Relevant Boxes)
<<Referral Criteria>>
* GPs are encouraged to attach a copy of the relevant part of the patient’s care plan to this form.
** Residents of a RACF generally rely on the facility for assistance to manage their type 2 diabetes. Therefore, residents may not need to be referred for allied health group services as the self-management approach may not be appropriate.
Please advise patients that Medicare rebates and Private Health Insurance benefits cannot both be claimed for this service.

Referring GP Details:
Dr Name:<<Doctor:Name>>
Practice Address: <<Doctor:Full Address>><<Doctor:Postcode>>
Provider Number: <<Doctor:Provider Number>>

Patient Details: 
Patient First Name:<<Patient Demographics:First Name>>   Patient Surname:<<Patient Demographics:Surname>>
Address: <<Patient Demographics:Full Address>><<Patient Demographics:Postcode>>

Note: Eligible patients may access Medicare rebates for one assessment for group services in a calendar year. Indicate the name of the practitioner (diabetes educator, exercise physiologist or dietitian), or the allied health practice, you wish to refer the patient to for this assessment. The assessment must be done before the patient can access up to 8 group services.

Allied Health Practitioner (AHP) or Practice the Patient is Referred to for Assessment:
Name of AHP or Practice: <<Name of AHP or Practice:>>
Address: <<Address:>>

Referring GP Signature:
Date: <<Miscellaneous:Date (long)>>

PART A - To be completed by Allied Health Professional who undertakes Assessment service
<<Suitability>>
Indicate the name of the provider/s, and details of the group service program:
Provider Name:<<Name of Provider/s:>>
Program Name:<<Name of Program:>>
Number of Sessions in Program: <<Number of sessions in the program:>>
Venue (If Known) <<Venue (n/a if unkown):>>
Name of Assessing AHP: <<Name of Assessing AHP:>>

AHP Signature:
Date: <<Miscellaneous:Date (long)>>

•	AHPs must provide, or contribute to, a written report to the patient’s GP after the assessment service and at completion of the group services program.
•	AHPs should retain a copy of the referral form for record keeping and audit purposes.
•	Allied health services funded by other Commonwealth or State/Territory programs are not eligible for Medicare rebates under these items, except where the service is operating under sub-section 19(2) arrangements.
THIS FORM DOES NOT HAVE TO ACCOMPANY MEDICARE CLAIMS