PATIENT ELIGIBILITY 

•	Health Care Card Holders
•	Pensioners or
•	Patients on a LOW income who would not otherwise be able to access a local service

If patient doesn’t satisfy one of these criteria, please refer using MBS or a private referral.

    Who should NOT be referred to providers under PAHS?

     X   Patients who can afford to pay for a private service
     X   Patients with Private Health Cover
     X   In-patients
     X   Residents living in Aged Care Facilities
     X   Department of Veterans Affairs Patients (DVA)

HOW TO REFER

•	All patients must have a PRIORITY ALLIED HEALTH SERVICES referral form (current version) and satisfy the eligibility criteria. Self-referrals can be accepted. Please complete all sections.
•	Allied Health Professionals (AHPs) and practice nurses are able to refer patients to appropriate PAHS services. The patients regular GP must be notified and included in correspondence between AHPs.
•	Patients are eligible for only one PRIORITY ALLIED HEALTH SERVICES referral, per Allied Health Service, in a 12 month period, except in extenuating circumstances.

Please Note: Referral letters from Medical Director and/or Best Practice will be accepted, however, notation must be made that the referral is under PAHS and include the patients consent to share personal information with the Allied Health Provider and HealthWISE.

TO MAKE AN APPOINTMENT

PATIENTS NEED TO CONTACT THE APPROPRIATE PROVIDER TO BOOK THEIR APPOINTMENTS.
PATIENTS NEED TO NOTIFY THE PROVIDER THEY HAVE AN PAHS/ HealthWISE REFERRAL FORM.

This referral will cover the actual session cost. There is no direct cost to the patient.

Patients are eligible to receive up to 6 sessions per PAHS referral – Number determined by the treatment plan.

Any additional materials or items provided will be at the patient’s own expense, unless otherwise arranged.

PATIENT DETAILS				
Name: <<Patient Demographics:Full Name>>    Date of Birth: <<Patient Demographics:DOB>>            Age:  <<Patient Demographics:Age>>
Address: <<Patient Demographics:Address>>                                             Phone:<<Patient Demographics:Phone (Home)>>
Alternative contact details: <<Patient Demographics:Phone (Mobile)>>        <<Patient Demographics:Phone (Work)>>                                      Date:<<Miscellaneous:Date (short)>>
ATSI:<<ATSI>> Concession Card /Low income:<<Concession Card/ Low Income>>
NOTE: Referrals under DVA, Workers Compensation and Third Party accident cases are ineligible for treatment under this program.
Reason for referral: (Tick service below): 
Referring GP/AHP Name:   <<Doctor:Name>>                                                      Referring GP/AHP Signature:
Medical Practice Name: <<Doctor:Full Details>>
Usual GP (if different to above):
NOTE: If available, please forward a copy of GPMP or TCA and/or recent pathology with referral, with patient’s permission. 
MEDICAL HISTORY 
<<Clinical Details:History List>>
Allergies:<<Clinical Details:Allergies>>
Medications:<<Clinical Details:Medication List>>
PATIENT CONSENT (must be signed at time of referral)
I understand that personal information regarding the reason for my referral may be shared with other care providers such as HealthWISE and their Allied Health providers. Any information held is strictly confidential and I give permission for these health professionals to access this information solely for the purpose of this referral.
Patient signature_______________________________________________________________________________     Date____/____/____ 

PLEASE HIGHLIGHT THE SERVICE REQUIRED FOR THIS REFERRAL

MANILLA:
<<Services required in MANILLA>>
KOOTINGAL AND NUNDLE: Appointments in Tamworth
<<Service required in KOOTINGAL and NUNDLE>>
ARMIDALE:
<<Services required in ARMIDALE>>
GLEN INNES: 
<<Services required in GLEN INNES>>
TENTERFIELD:
<<Services required in TENTERFIELD>>
WALCHA:
<<Services required in WALCHA>>
QUIRINDI:
<<Services required in QUIRINDI>>

GUYRA:
<<Services required in GUYRA>>
INVERELL:
<<Services required in INVERELL>>
TINGHA:
<<Services required in TINGHA>>