MBS Item	Service Description 	Recommended Frequency	*Minimum Claiming Period	Special Requirements	
721	Preparation of GP Management Plan (GPMP)	2 yearly	12 months	Chronic condition for at least 6 months or terminal condition	
723	Preparation of Team Care Arrangement (TCA)	2 yearly	12 months	Multidisciplinary team consisting of GP plus 2 or more other care providers	
732	Review of GP Management Plan	6 monthly	3 months	Must have Item 721	
732	Review of Team Care Arrangement	6 monthly	3 months	Must have Item 723	
10997	Chronic Disease Monitoring & Support by Practice Nurse/Aboriginal Health Worker	5 per calendar year	No time specified	Must have a GPMP to be eligible	
n/a	Yearly Referral to Allied Health Services (AHS) through Team Care Arrangement	5 visits per calendar year	n/a	Must have a current GPMP & TCA to be eligible for AHS Medicare rebate	
n/a	Yearly Referral to Diabetes Group Service	8 sessions per calendar year	n/a	Requires only a GPMP to be eligible for AHS Medicare rebate	

Date (Management Plan prepared): 	<TodaysDate>
Patient details	Doctor preparing the plan
(patient’s usual doctor)	
Name:<PtFullName> 

Address:  <PtAddress>      

Phone: (h) <PtPhoneH>
              (w) <PtPhoneWk>             
              (m)<PtPhoneMob>	Date of Birth:<PtDoB> 
Medicare no: <PtMCNo>
DVA no: <PtDVANo>
Aboriginal or Torres Strait Islander:  <ATSI origin>

	Name: <DrName>

Address:<Practice><UsrAddress>          

Phone: <UsrPhone>
Fax: <UsrFax>

Provider no: <DrProviderNo>	

Allergies / Warnings	
<Reactions>
	
Active Medical Problems:	Current Medications: 	Immunisations:	
<PMHActive>

	<CurrentRx>

	<Imm>	
Past Medical History: 	Family History	Social History/ Occupation  
	
<PMHAll>

	<FamilyHx>	<PtOccupation>
<SocialHx>	

General Recommended Goals						My Current Measurements
 Blood  
 sugars	•	Prevent heart, kidney, eye or nerve damage
•	Fasting blood sugar  4 – 6
•	HbA1 ≤ 7		Fasting Blood Sugar 

HbA1c	 
 <Fasting BSL>

<HbA1c>	
 Circulation 
	•	Monitor kidney function 
•	Detect vision problems
•	Prevent foot injury				
 Blood Fats	•	Cholesterol < 4
•	Triglycerides < 2
•	LDL < 2.5
•	HDL ≥ 1.0		Cholesterol 
Triglycerides 
LDL 
HDL 	 <Cholesterol>
 <Triglycerides>
 <LDL>
 <HDL>	
 Blood  
 Pressure	•	Blood pressure  < 130/80		Blood pressure  	 <Blood Pressure>	
 Weight
 
	•	Body Mass Index ≤ 25
•	Waist circumference
•	< 94cm for men
•	< 80cm for women		Weight
Height
BMI
Waist	 <Weight>
 <Height>
 <BMI>
 <Waist>	

General Recommended Actions				  	     General Recommended Actions
 currently I …
 Diet	Review diet and make healthier changes
•	Low saturated fat / low salt / low sugar / high fibre
•	2  fruit / 5 vegetables

	eat  <I eat>		Foot care	•      Daily foot care and        inspection	check my own feet <I check my feet>

 Exercise	Daily walking or other activity for at least 30 minutes that
•	Increases your heart rate
•	Makes you sweat, puff or pant
	exercise  <I do exercise>		Vision	•	Eye examination every 2 years	have had my eyes last checked on <Have had my eyes last checked>	
 Blood 
 sugar  
 levels	•	Measure blood sugar before meals or 2 hours after eating	measure my sugar level <Measure my blood sugar>		Teeth	•	Yearly dental check ups	have had my teeth last checked on <Have had my teeth last checked>
and have the following problems with <Have the current dental problems>

 Smoking	•	Discuss giving up with GP
•	Ring Quitline - Phone: 13QUIT (13 7848)	smoke <I smoke>		Mental Wellbeing	•	Stay motivated to achieve goals
•	Manage stress 

	I feel <I feel>	
 Alcohol	•	No more than 2 standard drinks per day (men)
•	No more than 1 standard drinks per day (women)
•	Have at least 2 alcohol free days per week	I drink <I drink>		Regular GP health checks 	•	Blood pressure, height , weight and foot checks
•	Review of diet, physical activity, medications, blood & urine tests	I see my GP for health checks <last saw my GP for a health check>	

What can be done to improve my health
 Patient problems / needs
 / relevant  conditions	 Goals / changes to be achieved
(made in collaboration with patient)	 Required treatments & services 
 including patient actions	
<My current problems and needs are>

	<My current goals/changes to be made are>

	<I require treatment and services for>

	

R	Others involved in my care plan	How they will contribute to my care	
<Tick if yes>	Endocrinologist  
<CntName>

	Regular monitoring and review of diabetes

<Tick if yes>
	Practice Nurse
 <CntName>

	Regular monitoring of general health parameters

<Tick if yes>	Podiatrist 
<CntName>

	Foot care & nail maintenance. Inspection for signs injury 

<Tick if yes>	Ophthalmologist 
<CntName>

	Regular eye examinations.  Monitor for early signs of eye damage 

<Tick if yes>	Dentist 
<CntName>

	Regular dental check-up.  Monitor for early signs of tooth decay or gum disease 

<Tick if yes>	Exercise Physiologist 
<CntName>	Develop an indivualised exercise program 

<Tick if yes>	Diabetic Educator 
<CntName>
	Provide an understanding of diabetes, treatment, diet and lifestyle 

<Tick if yes>	Dietitian 
<CntName>
	Develop an indivualised dietary program 

<Tick if yes>	Other Specialists / Services 
<CntName>
<CntName>

	    	

Consent

I agree with the goals and treatments set out in the above GP Management Plan and give permission for the above care and service providers to be involved. 
I give consent for the exchange of relevant information between the care / service providers included in the Team Care Arrangement and the GP.  

Review of GPMP (732) & TCA (732) next due:<ReminderReason>  <ReminderDate>        ( 6 monthly) 
New GPMP (721) & TCA (723) due: <ReminderReason><ReminderDate>  (2 yearly)

Signature of patient / carer		________________________				GP signature	__________________________

Patient / carer name			<PtFullName>	/ <Carer name>				GP name		<DrName>
Relationship to patient (if carer)	________________________________				Date		<TodaysDate>
Date					<TodaysDate>_

Current Relevant Investigations Attached:

 <Ix>