Elk Health Referral

Referral form

Client Details

Client Details:

First Name:

Last Name:

Gender:

Phone:

Mobile:

Date Of Birth:

Email:

Job Title:

Address 1:

Address 2:

City:

State:

Post Code:

Referral Details

Are you completing this referral on behalf of the client?:*

Referral Date:

Referrer Name:

Relationship to client:

Referrer Email Contact:

Is the client aware you are making this referral on their behalf?:

Therapy Services Required:*

Reason for Referral:*

NDIS Funded Referral

Funding Type:

NDIS Number:

Sorry we are unable to provide services to NDIA Managed participants at this time

Plan Manager Name :

Plan Manager Invoice Email:

NDIS Plan Start Date:

NDIS Plan End Date:

Funding available for FCA assessment / ongoing intervention:

NDIS Goal 1:

NDIS Goal 2:

NDIS Goal 3:

NDIS Goal 4:

NDIS Goal 5:

Aged Care Funding Referral

Please write a brief outline of client needs and other information that will assist with this referral:*

Medicare - GP chronic condition management plan (GPCCMP)

Medical practitioners can refer eligible patients with chronic conditions to allied health professionals. Allied health professionals can claim Medicare benefits for some services.

Eligible patients can use 5 services per calendar year. The 5 services may be either:

one type of service, for example 5 physiotherapy services
a combination of different types of services, for example one dietetic and 4 podiatry services.

Patients are eligible for these allied health services if their medical practitioner has completed a GPCCMP.

The referring medical practitioner decides whether the patient’s chronic condition would benefit from allied health services.

It isn’t appropriate for allied health professionals to:

provide a partly completed referral to a referring medical practitioner for signing
pre-empt the decision about the services that the patient requires.

Referrals under a GPCCMP are valid for the timeframe stated in the referral. If there’s no timeframe stated, they are valid for 18 months from the first service date provided under the referral.

To find out more information please visit https://www.servicesaustralia.gov.au/

Do you have a letter from your GP?:

Please Upload a photo of the GP letter:

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DVA Referral Details

Has a DVA Referral Form (DO904) been provided by a General Practitioner?:

To be able to provide services to you, we require a Allied Health Services treatment cycle referral. (form DO904)

Your health professional can email the referral through to hello@elkhealth.au

Further information can be found here: Allied Health Information Flyer for DVA Patients

DVA File Number:

Referral date:

Referring Clinician:

Condition to be treated:

Which Veteran Card do you hold?:

Start Workflow:

New referral Onboarding

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