Connect Referral

Patient Referral Form

PATIENT DETAILS

First Name

Last Name

Preferred Name

Date of Birth

Mobile Phone *

Email

Address

Purpose of treatment *

Current diagnosis

Gender

MaleFemale

English is a Second Language

YesNo

Ethnicity

ATSI

AboriginalTorres Strait IslanderNone of the Above

EMERGENCY CONTACT DETAILS

Name

Mobile Phone

Email

Referrers Details (Care Manager)

Name

Address

Email

Funding Mechanism *

Organisation

MEDICARE

Do you use a different name in your medicare card?

YesNo

If you use Alias please write the Alias name & surname

Medicare First Name

Medicare Surname

Medicare Card No.

Expiry

Medicare Address (if different to your residential address)

PRIVATE HEALTH INSURANCE

Do you have private Medical insurance

YesNo

Provider

Membership No.

Expiry

PENSION / HCC/DVA Card

Do you have an aged pension card, healthcare card or a DVA card

YesNo

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

DVA No.

WORKCOVER / CTP Claim

Workcover CTP Claim *

YesNo

Employer

Employer's Address

Claim Number

Occupation

Insurer

Insurer's Address

Date of Injury

Case Manager

Case Manager's Contact Number

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Terms and Conditions

I confirm I have read and agree to the following Terms and Conditions:

I understand and acknowledge that any services received by myself or the person in my legal care from AHP Connect (“the Clinician”) were at my request.
I understand that payment is to be made at time of consultation unless previously arranged with the principal of the Clinic.
For those on a Chronic Disease Management Plan - once all treatments under my Chronic Disease Management Plan have been completed, I agree that any further treatments I may require will be charged at AHP Connect’s standard rate without rebate
Cancellation & No Show Policy - We understand that unforeseen circumstances may arise requiring clients to cancel or reschedule their appointments. Policy as follows:

Cancellations made at least 24 hours before scheduled appointment will not incur any charges.
Cancellation requests made within 24 hours of the scheduled appointment will be subject to a cancellation fee of 50% of the session rate.
Failure to attend the appointment without any prior notice will result in a no-show fee equivalent to the full session rate.
Note that clients under NDIS and HCP funding are required to provide 48 hours notice to reschedule or cancel appointment otherwise will be subject to a full session cancellation rate.

*

Patient/ Guardian/ Referrers Signature/

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