Referral form

ABN: 33 648 888 608

Referral Form

Date of referral *

Who is filling out this form *

Please list the people on this call:

Which service(s) would you like to refer to: *

Occupational Therapy

Person being referred:

First Name *

Last Name *

Preferred Name

Date of Birth *

Phone number

Email

AddressInclude any specifics re parking or access

Referral Information

Describe why they would like help from Occupational Therapy (referral reason):

Person's diagnosis

Other information (e.g. best time to contact the person):

Are there any risks/safety concerns (such as behavioural or environmental risks):

Main Contact

First Name

Last Name

Relationship to person

Contact Phone number

Contact EmailPlease enter client's email address here if no alternative contact

Funding

NDIS Number *Please enter N/A if NDIS number is unknown

What category of funding is available for OT

Start of Plan *Please enter Today's date for start/end plan dates if unknown

End of Plan *

Billing email address *

Plan managed billing email address *

Please enter N/A if billing email address is unknown

Medicare Card Number *

Individual Reference Number *

Medicare Card Expiry Date *

Referring Doctor *

Referring Doctor's contact phone

Referring Doctor's Provider Number

Date of GP Referral

Please provide a copy of the GP Referral if able

Browse

Please provide any other information regarding this Referral

Browse

School attended

If Other school please specify

Send Service Agreement to: *

Please specify whom to send Service Agreement to *

Referrer's Details

We are self/primary contact referred

First Name

Last Name

Referrer's relationship to person

Other relationship

Referrer Phone

Referrer Email

The person being referred has given consent to this referral and consents to these details being kept on a cloud based client management system *

If Other, please specify

Would the Main Contact for the Client like reminders for the Client's appointments? *

Yes SMSNo SMSYes EmailNo Email

Review by Director

This Client is suitable for services *

YesNo

Clinician Allocated *

Next Steps *

Admin add to Waitlist, send Fees & Services. Do not need to set up funding plan.Admin accept immediately, send WT-JSTS and SA - please enter details

Hours/Dollars for SAPlease enter PRIVATE if you wish a Private SA to be sent, None/N/A if no SA required, EKC if Eden Kids Clinic referral.

Documents, Information and Fees & Services sent automatically to client/referrer

Review by Admin

Please fill in as many iinsight fields as possible in the iinsight Tabs: Client and Case with the information in this referral

Setup file in iinsight

SA steps

Reason for Referral added during setupAttached files uploaded (labelled Ref Info) including Ref Form that comes through when completed,Any extra emails re this referral in admin@ added to Admin NotesClient->Phone number copied into Mobile number fieldNDIS No. copied from Case->Claim No. also into Participant No. (if necessary)Claim plan due date updated in Case>Claim Plan Due Date (if necessary)

Documents Fees & Services sent automatically to client/referrer

If referral is accepted to clinician: Interim Funding plan setup in iinsight - using template CB Total Sum - monetary based
Use Plan dates above and $250 - note in comments box how many hours are approved in total to approve when SSA returned

If referral is accepted to clinician: Interim Funding plan setup in iinsight - using template CORE Total Sum - monetary based
Use Plan dates above and $250 - note in comments box how many hours are approved in total to approve when SSA returned

If referral is accepted to clinician: Interim Funding plan setup in iinsight - using template LASTNAME Total Sum - monetary based
Use Plan dates above and $250 - note in comments box how many hours are approved in total to approve when SSA returned

This is an EKC Referral - please set the Bill To as HPOS "To claim" and No SA required

Choose as appropriate:

Blank NDIS SA for input.

Blank Private SA for input

Sent Service Agreement for signing, Working Together Form is sent automatically with this.

Save and Complete Later