Referral Form for Dental Services under Medicare 	
	
To be completed by referring GP
Please indicate below whether patient has:
   a GP Management Plan and Team Care Arrangements in place (MBS CDM items 721 and 723):  <<Patient has a GPMP and TCA in place>> 
      OR
      an aged care resident has a multidisciplinary care plan in place (MBS CDM item 731) (MBS CDM item 731): <<Aged care resident has a care plan in place>> 
This referral is valid for 2 consecutive calendar years from the date of the patient’s first dental service (eg if the first service date is 15 November 2007, the referral is valid to 31 December 2008).	
GP details:	
Provider Number	<<Doctor:Provider Number>>	NOTE: Relevant chronic disease management (CDM) MBS item(s) above must be BILLED by GP prior to patient receiving their first referred dental service for Medicare rebate to be payable for that service.	

Name	<<Doctor:Name>>		

Address	<<Doctor:Full Address>>
Tel: <<Doctor:Phone>>  Fax: <<Doctor:Fax>>		

Patient Details:		

Medicare Number	
<<Patient Demographics:Medicare Number>>	Patient’s Ref. No.	<<Patient Demographics:Record Number>>	

First Name	
<<Patient Demographics:First Name>>	
Surname 	
<<Patient Demographics:Surname>>	

Address	
<<Patient Demographics:Full Address>>	

Dental Practitioner (or dental practice) details:
(GPs may refer eligible patients to a dentist.  Where a patient has no natural teeth and requires dental prosthetic services only, a referral may be made to a dentist or dental prosthetist.  Patients cannot be referred by a GP to a dental specialist).
	
Name
	<<Addressee:Name>>	
Address	<<Addressee:Full Address>>	
			
Referring General 
Practitoner’s signature		
Date Signed:	
<<Miscellaneous:Date>>		
	
IMPORTANT NOTE TO DENTISTS AND DENTAL PROSTHETISTS:
To refer patients onto another dental practitioner, dentists and dental prosthetists may use a referral note or letter (signed and dated).  
A copy of this GP referral form must be attached to the referral note/letter as the receiving dental practitioner will need the GP’s details and initial date of referral from the GP for Medicare billing.
	
Note: GPs are encouraged to attach a copy of the relevant part of the patient’s care plan/s to this form.
Clinical notes/ current medications attached (optional): <<Clinical notes/ current medications attached>>  
Copy of care plan attached:  <<Copy of care plan attached>>
	
Eligible patients may access Medicare benefits of up to $4,250 in total over two consecutive calendar years for dental 
services provided under items 85011-87777.	
For general enquiries about the Medicare dental items, contact Medicare Australia on 132 150.	
Dental practitioners should retain a copy of this referral form for record keeping and Medicare Australia audit purposes.	
Copies of this form and further information about this initiative are available at www.health.gov.au/epc
Copies of the form may also be ordered by faxing: (02) 6289 7120 or phoning: (02) 6289 4297	
THIS FORM DOES NOT HAVE TO ACCOMPANY MEDICARE CLAIMS