Connecting Care Program (Severe Chronic Disease Management Program)
Recommendation for Patient Enrolment 
Please complete all sections of this form and return to the Connecting Care Contact Centre on:
Fax No. 9881 7110.                                              For enquiries please phone 1800 339 144.
Patient Name:<PtFullName>		AUID or MRN: 
(Local Health District staff only)	
Medicare Number:<PtMCNo>	Date of Birth:<PtDoB>	Sex: (please tick) <PtSex>   
                                            	
Address:<PtAddress>
	Suburb:<PtCity>	Postcode:<PtPostcode>	
Home Phone:
<PtPhoneH>
	Other Phone:
<PtPhoneMob>
<PtPhoneWk>	Alternate Contact Name and relationship: 
<NOKName>
<NOKRelation>	Contact Number: 
<NOKContact>	
Country of Birth:
<Country of Birth>
	Interpreter required?: <Interpreter needed>
                   
                                                                    	Preferred Language:<Preferred language>	
Is the patient of Aboriginal or Torres Strait Islander descent? (please tick)

 <Aboriginal?>Aboriginal         Torres Strait Islander<Torres Strait Islander>        Aboriginal and Torres Strait Islander<Aboriginal and Torres Strait Islander>	
General Practitioner – Name, suburb and phone number:
<DrName>
<DrAddress>
<DrPhone>
	Specialist and specialty:
<Specialist and Specialists fields>	
Chronic Conditions: (please mark Y/N)
 Heart failure : <Heart Failure>                
 Diabetes :  <Diabetes>             
 Coronary Artery Disease :  <Coronary Artery Disease>      
 Hypertension :  <Hypertension>               
 Chronic Obstructive Pulmonary Disease:  <COPD>                                                                                 
	
Other factors for consideration (eg. health, psychological, cognitive, social, environment and lifestyle factors): 
<Other factors for consideration>
	
Name of primary carer or person responsible:    <Name of carer or person responsible> 
Contact details:    <Contact details of carer or person responsible>
Carer information (if relevant): <Carer information (if relevant)>
	
Key services and supports involved in patient’s care and wellbeing:<Key services and supports involved in patients care>
	
Checklist of accomanying information – if known: (please tick)	
Consent form signed by client                    
<Consent form signed by client>     	Comprehensive assessment or summary        
 <Comprehensive assessment or summary>   	
GP Management Plan
<GP Management Plan>                                 	Team Care Arrangement
<Team Care Arrangement>                                        	
Shared Care Plan                                          Yes             No         	Discharge Summary                                              Yes             No         	
Other accompanying information: (please detail)<Other accompanying information e.g.speicalist letters, path>	
Referrer name, service and phone number:
<DrDetails>	
Date Received:(office use only)                                                  Actioned By:(office use only)                  
Form No.           SWA – 198 NBM                                                                                                                                   July 2011