RiTH Referral Form - InterHealthcare

Patient Details

Title

Given Name*

Other Name

Surname*

Address*

Suburb*

State*

Post Code

Date of Birth*

Home Phone

Mobile*

Email*

Doctors Details

Referring Doctor *

Referring Doctor Phone

Specialist (if different to Referring Dr)

Specialist Phone

Specialist Email

GP Phone

GP Email

Hospital Details

Hospital

Ward

Admission Date *

Discharge Date *

Inpatient Rehab Admission*

Yes No

Interpreter Required

Yes No

Aboriginal and/or Torres Strait Islander

RELEVANT MEDICAL INFORMATION

Reason for Hospital Admission

Surgical Procedure (if applicable)

Date

Relevant Medical History/Co-morbidities

Allergies

Services Required

Rehabilitation in the Home Hospital in the Home

Is the patient suitable for telehealth?

Yes No

Does the patient consent to telehealth?

Yes No

Additional Information

REFERRER DETAILS

I confirm I have informed the patient and obtained their consent that:
A: Their personal information (including health information) will be shared with InterHealthcare Community Care for the purpose of providing at home services ("Service")
B: InterHealthcare will contact the patient about the Services and their nominated Next of Kin if InterHealthcare has not been able to contact the patient after three attempts. The Next of Kin will be asked to get the patient to call InterHealthcare to discuss next steps.
C: If applicable, InterHealthcare may be required to disclose their personal information to their health fund, or their health fund's authorised agency(ies) to ascertain eligibility for the Services, confirm receipt of Services and facilitate their participation in the Services. All parties involved with this program are bound by strict obligations of confidentiality and privacy. *

Referrer Name *

Title *

Phone *

Email address to receive communications from InterHealthcare *

Date

RiTH - Referral Form

RELEVANT MEDICAL INFORMATION

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