Amplar Home Health Referral for Services

Amplar Home Health Referral for Services

Ph: 1800 854 300 Email: home@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.
Sign 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 referral 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 populatewhen 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.

PATIENT DETAILS

Title

Given Name *

Other Name

Surname *

Address *

Suburb *

State *

Post Code *

Date of Birth *

Home Phone *

Mobile *

Email

Medicare No.

Medicare Reference NumberThis refers to the single digit number next to the person's name on their Medicare card.

Next of Kin Details (Amplar Home Health requires each referral to have a nominated next of kin).

Given Name *

Surname *

Next of Kin Relationship *

Next of Kin Phone *

Next of Kin Email

Doctors Details

Referring Doctor *

Referring Doctor Phone

Referring Doctor Email

Specialist (if different to Referring Dr)

Specialist Phone

Specialist Email

GP

GP Phone

GP Email

Hospital Details

HospitalPlease provide the name of the referring hospital.

Ward

Admission Date *

Discharge Date *

Inpatient Rehab Admission *

Yes No

Interpreter Required

Yes No

Aboriginal and/or Torres Strait Islander

If Yes, how many days? *

Specify Language

FUNDING

Please select one of the following funding options.

Health FundSelf Funded/OtherHospital Funded

Funder Details

Contact Details for Invoice

Fund Name *

Membership No. *

DRG

HT

Suffix NumberPlease ensure the Membership and Suffix numbers are correct for the claim to be processed.

Number of Visits *

Service Type *

Provider *

Claim No. *

Case Manager *

Case Manager Phone *

Case Manager Email *

RELEVANT MEDICAL INFORMATION

Reason for Hospital Admission

Surgical Procedure (if applicable)

Date

Relevant Medical History/Co-morbidities

Allergies

Other (Specify)

SERVICES REQUIRED

Rehabilitation in the Home

Hospital in the Home

Please select one of the three options below *

JointMedibank No Gap OrthopaedicsOther

Please select services required *

PhysiotherapyOccupational TherapyNursing (including wound review where required)Other (Specify)

Other Specify

Wound Management

Please attach the wound chart.

Drain Management

Please provide clear instructions on the drain management required.

If flushing is required a Medication Authority will be required to be uploaded.

If a PleruX Drain plese specific amount to be drained and frequency.

Please add these details in the Additional Information field.

IV Antibiotics

Please provide a copy of the script, PICC details, subsequent pharmacy details, medication chart and sensitivities (if required for high cost medications).

Please add this information to the correspnding fields below.

Other

Is the referral in lieu of an inpatient hospital stay?

YesNo

The patient would otherwise stay in hospital for how many days without home services?

Is the patient suitable for telehealth?

YesNo

Does the patient consent to telehealth?

YesNo

CURRENT CARE NEEDS

Other: Specify *

Falls Risk *

HighMediumLow

Further Information

Cognition *

Alert/OrientatedMildly Confused Very ConfusedOther: Specify

Other: Specify *

Living Arrangements *

Community Services Involved

Yes: SpecifyNo

If 'Yes', please list all community services involved below (list each community service in a separate field) and number of visits for each service listed.

Community Service *

Number of Visits *

Community Service

Number of Visits

Community Service

Number of Visits

Community Service

Number of Visits

Community Service

Number of Visits

NPWT

NPWT Type *

Device No *

Dressing type / size *

Frequency *

IV Antibiotic Therapy

What Type? *

PICC / POC dressing due *

PICC / POC Location *

Number of Lumens *

Gripper Needle Size (POC)

Upload Medication Authority *

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ATTACHMENTS

For RITH, if available please ensure Discharge Summary and Allied Health report are uploaded below.

If the above are not available please attach in the 'other attachment' field an appropriate substitute such as a progress note from a Physio stating the patients mobility, goals to be achieved and level of assistance required.

Upload Discharge Summary

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Upload Allied Health report

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Other Attachments

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For HITH, if avialble please ensure the Discharge Summary, Medication Authority, and Scripts are uploaded below. If a Wound Chart and/or Culture & Sensitivities Report are also available, please upload.

If the above are not available please attach in the 'other attachment' field other supporting documents.

Please note: Amplar Home Health cannot process the referral if the relevant supporting documents are not provided.

Upload Discharge Summary

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Upload Medication Authority

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Upload Scripts

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Upload Wound Chart (if applicable)

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Upload Culture & Sensitivities Report (if applicable)

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Other Attachments

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ADDITIONAL INFORMATION

Notes

For HITH

Subsequent Pharmacy

Commencement Date

CHECKLIST (Please tick or leave blank)

For Rehabilitation in the Home Referrals

I have completed and attached an allied health report

Yes No

I have attached a specialist protocol (if applicable)

Yes No

For Hospital in the Home Referrals

I will send the patient home with 3 days of consumables (if applicable) *

Yes No

I have attached an allied health report or discharge summary

Yes No

I have completed and attached a wound care chart (if applicable)

Yes No

I have attached the patient’s scripts (if applicable)

Yes No

I have included relevant PICC / PORTA CATH information (if applicable)

Yes No

I have completed and attached a medication authority

Yes No

I have attached Culture & Sensitivities report

Yes No

I have referred the patient to a long term care provider.

YesNo

Provider Name? *

Start Date *

REFERRER DETAILS

By signing below, I confirm I have informed the patient that:
A: Their personal and health information will be shared with Amplar Home Health for the purposes of the referral.
B: Amplar Home Health will contact the patient about the services. If they cannot be contacted after three attempts, their nominated contact person will be contacted to discuss steps to arrange the services.
C: Amplar Home Health may share their personal information with:

funders of the service to facilitate their participation in the services; and
Amplar Allied Health if allied health services are required.

Referrer Name *

Title *

Phone *

Email address to receive communications from Amplar Home Health *

Signature *

Draw signature|Type signatureClear

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