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: <<Patient Demographics:Full Name>>

AUID or MRN: 
(Local Health District staff only)

Medicare Number:<<Patient Demographics:Medicare Number>> | Date of Birth:<<Patient Demographics:DOB>> | Sex:<<Patient Demographics:Sex>>
Address:<<Patient Demographics:Address Line 1>> | Suburb:<<Patient Demographics:City>> | Postcode:<<Patient Demographics:Postcode>>

Home Phone:
<<Patient Demographics:Phone (Home)>>

Other Phone:
<<Patient Demographics:Phone (Work)>><<Patient Demographics:Phone (Mobile)>>

Alternate Contact Name and relationship: 
<<Alternate contact Name and relationship>>

Contact Number: 
<<Alternative contact no.>>

Country of Birth:
<<country of birth>>

Interpreter required?: <<Interpreter required>>

Preferred Language:<<Preferred language>>

Is the patient of Aboriginal or Torres Strait Islander descent? 
<<Is the Aborginal, Torrest Strait Islander or both>>

General Practitioner – Name, suburb and phone number:
<<Doctor:Full Address>>

Specialist and specialty:
<<Specialist or specialty>>

Chronic Conditions: (please mark Y/N)
 Heart failure: <<Heart Failure>>
 Diabetes:  <<Diabetes>>
 Coronary Artery Disease : <<CHD>>
 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 Primary Carer>>
Contact details:  <<Carer contact details>>
Carer information (if relevant): <<Other relevant carer information>>

Key services and supports involved in patient’s care and wellbeing:<<key support services involved in patients care>>
Checklist of accomanying information – if known: (please tick)
Consent form signed by client: <<consent form signed>> | Comprehensive assessment or summary: <<Comprehensive or summary attached>>
GP Management Plan: <<GPMP attached>> | Team Care Arrangement attached: <<TCA attached>>
Shared Care Plan: <<Shared care plan attached>> | Discharge Summary: <<Discharge summary attached>>
Other accompanying information: (please detail)<<Other accompanying information>>
Referrer name, service and phone number:
Date Received:(office use only)                                                  Actioned By:(office use only)                  
Form No.           SWA – 198 NBM                                                                                                                                   July 2011