This program supports Aboriginal and Torres Strait Islander people with complex chronic care needs to improve 
self-management of their condition in partnership with their GP. 

Referring GP Details: (stamp accepted)		
Name:			
Practice:			
Practice Address:			
Phone:	Fax:		
Patient Details:			
First Name:		Date of Birth:	
Surname:		Phone:	
Residential Address:		Postcode:	
Next of Kin/Alternate Contact:		Alternate Contact Phone:	
 My patient meets ALL the criteria below (tick applicable):
Is Aboriginal and/or Torres Strait Islander
Has chronic health needs requiring complex and/or multidisciplinary care
Has a chronic condition management plan

   Type of Chronic Disease Management Plan (attached)
        Current GP Management Plan MBS721

        Interim referral options are accepted but a GPMP must be provided within three months
            Referral by non-usual GP or Remote Area Nurse (RAN) with an interim CDM care plan, or
            Team Care Arrangements MBS723; or 
             Current Aboriginal Health Check MBS715 and is registered for PIP IHI for CDM with referring practice

Chronic Condition Details (tick applicable)	
•	Diabetes
•	Cardiovascular disease	•	Chronic renal disease
•	Chronic respiratory disease	•	Co-occurring mental health condition 
•	Cancer 	
•	Other 	
Is another organisation already currently providing care coordination? If yes, specify:	
..............................................................................................................................................................................................
E.g. Aboriginal Community Controlled Health Service; ICDC Program; Aged Care Provider. Provide Client ID Number if available	

NDIS and Aged Care:		
Is the client registered for NDIS:	•	Yes	•	No	•	In progress	
Is the client registered for Aged Care support:	•	Yes, Level (circle): 1 2 3 4	•	No	•	In progress	
The ITC Program must not duplicate services for people eligible for a funded package.	
Reason/s for ITC Referral:				
•	Requires supplementary services support	•	Requires care coordination support	
THE ITC PROGRAM IS ONLY ABLE TO PROVIDE SUPPORT RECOMMENDED IN THE GP CARE PLAN AND NOT AVAILABLE THROUGH OTHER MEANS.
Comments:
..............................................................................................................................................................................................
..............................................................................................................................................................................................
 Patient Information and Consent		
My GP has explained the purpose of this referral for the ITC Program; I give permission for my care plan to be shared with the ITC Provider; and for the ITC Provider to contact me to discuss how the ITC Program can support me in my care plan needs.	
Patient signature:

Verbal consent (where signature not practicable) 	GP signature:

Date:	

Forward completed ITC Referral Form, patient care plan and other relevant documents to ITC Provider preferably via secure messaging. 
WA ITC Providers		
PERTH NORTH PHN  (see Health Pathways for suburb list)	
Subregion 	Service Provider 	Contact	Fax	Secure messaging  	
North West 	Arche Health 	P: 08 9458 0505            Free call: 1300 182 820

E: aht@archehealth.com.au	08 9458 8733	MMEx	
North East 	Moorditj Koort 	P: 08 6174 7000

E: info@moorditjkoort.com.au	08 6174 7098	MMEx	
PERTH SOUTH PHN  (see Health Pathways for suburb list)	
Subregion 	Service Provider 	Contact	Fax	Secure messaging  	
South West 
(Mandurah, Waroona, Murray (6213))	Nidjalla Waangan Mia (NWM)
Operated by GP Down South	P: 08 9586 4580	08 6117 0489	HealthLink	
South West 	Moorditj Koort 	P: 08 6174 7000

E: info@moorditjkoort.com.au	08 6174 7099 (Medina)
08 6174 7097 (Cockburn)	MMEx	
South East 	Arche Health 	P: 08 9458 0505            Free call: 1300 182 820

E: aht@archehealth.com.au	08 9458 8733	MMEx	
COUNTRY WA PHN	
Subregion 	Service Provider 	Contact	Fax	Secure messaging  	
Kimberley 	Boab Health Services 	P: 08 9192 7888 (Broome)
P: 08 9168 2560 (Kununurra)	08 9192 7999
08 9168 2560	MMEx	
Midwest (South)	Geraldton Regional Aboriginal Medical Service (GRAMS)	P: 08 9956 6555	08 9964 3225	Communicare	
Midwest (North)	GRAMS Gascoyne Outreach Service	P: 08 9947 2200	08 9941 2024	Communicare	
Pilbara 	Mawarnkarra Health Service Aboriginal Corporation	P: 08 9182 0851

E: mhsitc@mhs.org.au 	08 9182 1055	Communicare	
South West 
	South West Aboriginal Medical Service (SWAMS)	P: 08 9726 6000            Free call: 1800 779 000	08 9791 7655	Communicare	
Wheatbelt
(Central & Western)
	Wheatbelt Health Network	P: 08 9621 4444

E: northam@wheatbelt.com.au
	08 9621 2119	HealthLink
	
Wheatbelt
(Southern, Coastal & Eastern)	Amity Health
 	P: 08 9842 2797

E: query@amityhealth.com.au	08 9842 2798	MMEx
	
Goldfields 
	Hope Community Services 	P: 08 9021 3069 (Kalgoorlie & Northern)
P: 08 9071 5169 (South East Coastal)

E: ITCAllStaff@hopecs.org.au	08 9021 8920
08 9071 5209	MMEx
	
Great Southern 	Amity Health 	P: 08 9842 2797

E: query@amityhealth.com.au	08 9842 2798	MMEx