Amplar Allied Health Referral for Services

ReferenceID

PractitionerID

Amplar Allied Health Referral for Services

Ph: 1300 660 086 Email: alliedreferrals@amplarhealth.com.au

Instructions

Complete all fields with relevant information.
Please note: The fields marked with * are mandatory. These sections must be completed to be able to submit the form.
To submit your referral, click the ‘ Submit ’ button at the bottom of the page.
A confirmation window will open to let you know when your referra l has been submitted.

Please note:

This is a secure and confidential way to submit the information entered to protect the privacy of our clients.
Relevant fields will populate when certain information is added.

To 'Save & Complete Later', ' Print' or ‘ Save as a PDF', please refer to the instructions at the bottom of the page.

CLIENT DETAILS

The following section refers to the client who is being referred for a service.

Client Title

Client Given Name *

Client Other Name

Client Surname *

Client Address *

Client Suburb *

Client State *

Client Postcode *

Client Date of Birth *

Client Email

Does the client have a Mobile phone number? *

YesNo

Client Mobile Phone Number: *Mobile number MUST be in format +614XXXXXXXX

Does the client have a Home phone number? *

YesNo

Client Home Phone Number: *

Aboriginal and/or Torres Strait Islander: *

Interpreter Required *

Yes No

Note: Amplar Allied Health does not have an interpreter service. We will discuss with the client (or their representative) at initial contact and support the client with their interpreter arrangements.

Specify Language: *

REFERRAL TYPE

Is this referral urgent?

Why is this referral considered urgent? *

Please select your referral type: *

CAS-number *

Details of 'other' referral type: *

Who is responsible for payment of invoice for this service? *

ClientFamily Member/Significant OtherOther

Note: Amplar Allied Health does not bulk bill Medicare CDM referrals. Payment is required at the time of the service.

'Invoice To' Name: *

'Invoice To' Email Contact: *

'Invoice To' Contact Phone Number: *Mobile number MUST be in format +614XXXXXXXX

Case Manager First Name: *

Case Managers Surname *

Case Managers Organisation *

Case Manager Phone Number: *Mobile number MUST be in format +614XXXXXXXX

Case Manager Email:

Client Medicare Number: *

Client Medicare Reference Number: *This refers to the single digit number next to the person's name on their Medicare card.

Client DVA Number: *

Client DVA Card Type: *

Client Health Fund Name (if applicable):

Client Health Fund Membership Number:

Name of Insurer: *

Claim Reference Number: *

Reason/s for Referral: *

SERVICES REQUIRED

Professions (select all that apply): *

PhysiotherapyOccupational TherapyPodiatryDietitian (Service available by Telehealth only)

Occupational Therapy: Individual requests e.g. aids and equipment – by the hour *

Allied Health Clinician *

OT Referral Type *

Individual requests - By the hour (e.g. aids and equipment, does not include home environment assessment)Basic Package - up to 3 hours (e.g. equipment prescription (2-3 items), installation of grab rail)Comprehensive Package- up to 5 hours (e.g. equipment prescription 4+ items, basic ramp access, multiple minor home modifications, complex equipment, motorised scooters/wheelchairs)Complex Package - up to 7 hours (e.g. bathroom remodels, stair lift, complex ramping)

Where will this/these service/s be delivered? *

Client's Home (as listed in 'Client Details' section above)Other Location (please provide details)

'Other' Location Type: *

Family Member/Significant Other's HomeRespite Care/Facility/Assisted LivingTemporary Accommodation eg Hotel, Airbnb, etc.

'Other' Location Address: *

'Other' Location Suburb: *

'Other' Location State: *

'Other' Location Postcode: *

RELEVANT MEDICAL INFORMATION

Has there been any recent (in last 6 months) hospital admissions?

YesNo

Reason for Hospital Admission:

Surgical Procedure Date (if applicable):

Admission Date:

Discharge Date:

Relevant Medical History/Co-morbidities: *

Allergies:

Other (Specify):

NEXT OF KIN (NOK) DETAILS (OR POWER OF ATTORNEY)

NOK Given Name:

NOK Surname:

NOK Phone Number:Mobile number MUST be in format +614XXXXXXXX

NOK Email:

NOK Relationship:

NOK 'Other' Relationship Details:

GENERAL PRACTITIONER DETAILS

GP First Name:

GP Surname:

GP Phone Number:Mobile number MUST be in format +614XXXXXXXX

GP Provider Number:

GP Email:

ATTACHMENTS

For CDM and DVA referrals, a copy of the referral must be uploaded otherwise the client will be invoiced as a 'private' client (and will be required to self-pay).

Upload GP Referral for CDM & DVA here: *

Browse

If you have selected the dietetics service please upload any of the following if available:

Pathology Tests (blood results)
Food Chart/Diary
Weight History

Note: You can still proceed with the service if the above is not available.

Upload Dietetics Attachments here:

Browse

If available please ensure any relevant Discharge or Medical Summaries are uploaded below.

Upload Discharge/Medical Summary here:

Browse

Upload 'Other' Attachments here:

Browse

ADDITIONAL INFORMATION

Is the Client suitable for telehealth (where clinically appropriate)? *

YesNo

Does the client consent to telehealth (where clinically appropriate)?

YesNo

Please provide any other additional information here:

REFERRER DETAILS

I confirm I am the client, or alternatively that I have informed the client, and therefore provide/have obtained client consent that:
A: Client personal information (including health information) will be shared with Amplar Allied Health for the purpose of providing at-home services ("Service")
B: Amplar Allied Health will contact the client about the Services (or their nominated NOK/POA if Amplar Allied Health has not been able to contact the client after three attempts. The NOK/POA will be asked to get the client to call Amplar Allied Health to discuss the next steps).
C: If applicable, Amplar Allied Health may be required to disclose the client's personal information to ascertain eligibility for the Services, confirm receipt of Services, and facilitate their participation in the Services. All parties involved with Amplar Allied Health services are bound by strict obligations of confidentiality and privacy. *

Referrer Title

Referrer First Name: *

Referrer Last Name: *

Referrer Relationship to Client:

Referrer Contact Phone Number: *Mobile number MUST be in format +614XXXXXXXX

Referrer Contact Email:

Referrer Signature: *

Draw signature|Type signatureClear

Signed Date:

Save & Complete Later Instructions:

If you are unable to complete all sections of the form and/or need to complete it later, please follow the below steps:

Click the ' Save and Complete Later' link at the bottom of the page.
You’ll be prompted to enter your email address, where a link will be sent so you can access and complete the form later.
To submit your referral, click the ‘ Submit’ button at the bottom of the page.

Please note: You will need to complete this process again if you wish to save a new draft.

Printing Instructions:

To print a copy of the completed form, please follow the below steps before you click ‘Submit’, as you are unable to print the form once it has been submitted.

Complete all relevant information.
Right click on form.
Select ' Print'.
Print as per normal printing processes.
To submit your referral, click the ‘ Submit’ button at the bottom of the page.

Save As PDF Instructions:

To save a copy of the completed form in PDF format, please follow the below steps before you click ‘Submit’, as you are unable to save the form once it has been submitted.

Complete all relevant information.
Right click on form.
Select ' Print'.
Select ' Save as PDF' in the ‘Printer’ drop down box options.
Click on ' Save'.
Save as per normal saving processes.
To submit your referral, click the ‘ Submit’ button at the bottom of the page.

Save and Complete Later

Amplar Allied Health is a business of Healthstrong Pty Ltd (ABN 61 155 277 919)