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ffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff030000000000}\par}
{\footer\pard\plain\f0\fs24\par}\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs12\par\trowd\trgaph57\trleft0\trpaddl0\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrb\brdrs\brdrw10\cellx10746\pard\widctlpar\intbl\pard\intbl\qc\sa113\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs28\b Referral Form for Dental Services under Medicare\plain\f1\fs24\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr40\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\intbl\sb120\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\b\cf4 To be completed by referring GP \plain\f0\fs18\cf4 (please tick the relevant box below):\plain\f0\fs18\b\cf4\cell\intbl\row\pard\trowd\trgaph57\trleft-57\trpaddl57\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clcbpat5\cellx473\clvertalc\clbrdrr\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f3\fs28 q\plain\f3\fs36\cell\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 Patient has a GP Management Plan and Team Care Arrangements in place (MBS CDM items 721 \plain\f0\fs18\ul\cf4 and\plain\f0\fs18\cf4  723); or \plain\f0\fs18\cell\intbl\row\pard\trowd\trgaph57\trleft-57\trpaddl57\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clcbpat5\cellx473\clvertalc\clbrdrr\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f3\fs28 q\plain\f0\fs18\cell\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 Aged care resident has a multidisciplinary care plan in place (MBS CDM item 731)\plain\f0\fs18\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr40\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 This referral is valid for 2 consecutive calendar years from the date of the patient\loch\f0\hich\f0 \'92s first dental service (eg if the first service date is 15\~November 2007, the referral is valid to 31 December 2008).\plain\f0\fs18\b\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr40\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clcbpat5\cellx1608\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\clpadr57\clpadfr3\cellx10746\pard\widctlpar\intbl\pard\intbl\sa120\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\b\cf4 GP details\plain\f0\fs18\b\cell\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs17\b\cf4 NOTE: Relevant chronic disease management (CDM) MBS item(s) above must be BILLED by GP prior to patient receiving their first referred dental service for\plain\f1\fs17\b\cf4  \plain\f0\fs17\b\cf4 Medicare rebate to be payable for that service.\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx1577\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt57\clpadft3\cellx5546\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx10743\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 Provider Number\plain\f0\fs18\cell{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Doctor:Provider Number>>{\*\txfieldend}\plain\f0\fs18\cell\cell\intbl\row\pard\trowd\trgaph57\trleft0\trpaddl0\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clcbpat5\cellx1577\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx5546\clvertalt\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx10743\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\cell\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx1577\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt57\clpadft3\cellx5546\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clpadt57\clpadft3\cellx10743\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 Name\plain\f0\fs18\cell{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Doctor:Name>>{\*\txfieldend}\plain\f0\fs18\cell\cell\intbl\row\pard\trowd\trgaph57\trleft0\trpaddl0\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clcbpat5\cellx1577\clvertalt\clcbpat5\clpadt57\clpadft3\cellx5546\clvertalt\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx10743\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\cell\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx1577\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt57\clpadft3\cellx8260\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt57\clpadft3\cellx10612\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx10746\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 Address\plain\f0\fs18\cell\pard\s17\intbl\tqc\tx4153\tqr\tx8306\tx8505\tx9072\tx9639\tx10206\tx10773\tx11340\tx11907\tx12474\tx13041\tx13608\tx14175{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Doctor:Address>>{\*\txfieldend}\plain\f0\fs18  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Doctor:City>>{\*\txfieldend}\plain\f0\fs18  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Doctor:State>>{\*\txfieldend}\plain\f0\fs18\cell\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 Postcode  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18\cf4 <<Doctor:Postcode>>{\*\txfieldend}\plain\f0\fs18\cell\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\intbl\sb120\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\b\cf4 Patient details\plain\f0\fs18\b\cell\intbl\row\pard\trowd\trgaph0\trleft0\trpaddl40\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx1577\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt57\clpadft3\cellx5228\clvertalt\clbrdrl\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx5559\clvertalt\clcbpat5\clpadt57\clpadft3\cellx6946\clvertalt\clpadt0\clpadft3\clpadr0\clpadfr3\cellx7120\clvertalt\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx10746\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 Medicare Number\plain\f0\fs18\cell\pard\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Patient Demographics:Medicare Number>>{\*\txfieldend}\plain\f0\fs18\cell\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\cell\pard\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph57\trleft-57\trpaddl57\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clcbpat5\cellx1577\clvertalt\clcbpat5\cellx5228\clvertalt\clcbpat5\cellx5559\clvertalt\clbrdrr\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\cell\cell\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx1577\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt57\clpadft3\cellx5228\clvertalt\clbrdrl\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx5559\clvertalt\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx6946\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt57\clpadft3\cellx10612\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx10746\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 First Name\plain\f0\fs18\cell{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Patient Demographics:First Name>>{\*\txfieldend}\plain\f0\fs18\cell\cell\plain\f0\fs18\cf4 Surname\plain\f0\fs18\cell{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Patient Demographics:Surname>>{\*\txfieldend}\plain\f0\fs18\cell\cell\intbl\row\pard\trowd\trgaph57\trleft0\trpaddl0\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clcbpat5\cellx1577\clvertalt\clbrdrt\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx5228\clvertalt\clcbpat5\clpadt57\clpadft3\cellx5559\clvertalt\clcbpat5\clpadt57\clpadft3\cellx6946\clvertalt\clcbpat5\clpadt57\clpadft3\cellx10612\clvertalt\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx10746\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\cell\cell\cell\cell\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx1577\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt57\clpadft3\cellx8260\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt57\clpadft3\cellx10612\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx10746\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 Address\plain\f0\fs18\cell\pard\s17\intbl\tqc\tx4153\tqr\tx8306\tx8505\tx9072\tx9639\tx10206\tx10773\tx11340\tx11907\tx12474\tx13041\tx13608\tx14175{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Patient Demographics:Address>>{\*\txfieldend}\plain\f0\fs18  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Patient Demographics:City>>{\*\txfieldend}\plain\f0\fs18  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Patient Demographics:State>>{\*\txfieldend}\plain\f0\fs18\cell\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 Postcode  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18\cf4 <<Patient Demographics:Postcode>>{\*\txfieldend}\plain\f0\fs18\cell\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\intbl\sb120\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\b\cf4 Dental practitioner (or dental practice) details  \par\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 (GPs may refer eligible patients to a dentist.  Where a patient has no natural teeth and requires dental prosthetic services only, a referral may be made to a dentist or dental prosthetist.  Patients cannot be referred by a GP to a dental specialist).\plain\f0\fs18\b\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx1577\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt57\clpadft3\cellx6866\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx10743\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 Name\plain\f0\fs18\cell{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Addressee:Name>>{\*\txfieldend}\plain\f0\fs18\cell\cell\intbl\row\pard\trowd\trgaph57\trleft0\trpaddl0\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clcbpat5\cellx1577\clvertalt\clbrdrt\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx6866\clvertalt\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx10743\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\cell\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx1577\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt57\clpadft3\cellx8260\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt57\clpadft3\cellx10612\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx10746\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 Address\plain\f0\fs18\cell{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Addressee:Address 1>>{\*\txfieldend}\plain\f0\fs18  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Addressee:City>>{\*\txfieldend}\plain\f0\fs18  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Addressee:State>>{\*\txfieldend}\plain\f0\fs18\cell\plain\f0\fs18\cf4 Postcode  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18\cf4 <<Addressee:Postcode>>{\*\txfieldend}\plain\f0\fs18\cell\pard\intbl\qj\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph57\trleft0\trpaddl0\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clcbpat5\cellx2246\clvertalt\clcbpat5\clpadt57\clpadft3\cellx5248\clvertalt\clcbpat5\clpadt57\clpadft3\cellx6567\clvertalt\clcbpat5\clpadt57\clpadft3\cellx8610\clvertalt\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx10746\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\b\cf4\cell\plain\f0\fs18\cell\cell\cell\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx2246\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clpadt57\clpadft3\cellx5248\clvertalt\clbrdrl\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx6567\clvertalt\clbrdrb\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx8610\clvertalt\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx10746\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\b\cf4 Referring General \line Practitioner\loch\f0\hich\f0 \'92s signature\plain\f0\fs18\cell\cell\cell\cell\cell\intbl\row\pard\trowd\trgaph57\trleft0\trpaddl0\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx2246\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt57\clpadft3\cellx5248\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx6567\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt57\clpadft3\cellx8610\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\clpadt57\clpadft3\cellx10746\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\b\cf4\cell\plain\f0\fs18\cell\pard\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 Date signed\cell\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18\cf4 <<Miscellaneous:Date>>{\*\txfieldend}\plain\f0\fs18\cell\cell\intbl\row\pard\trowd\trgaph57\trleft0\trpaddl0\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\s2\intbl\sb120\tx375\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\b\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\intbl\sb120\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\b\cf4 IMPORTANT NOTE TO DENTISTS AND DENTAL PROSTHETISTS:\par\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 To refer patients onto another dental practitioner, dentists and dental prosthetists may use a referral note or letter (signed and dated).  A copy of this GP referral form \plain\f0\fs18\ul\cf4 must be attached\plain\f0\fs18\cf4  to the referral note/letter as the receiving dental practitioner will need the GP\loch\f0\hich\f0 \'92s details and initial date of referral from the GP for Medicare billing.\plain\f0\fs18\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\intbl\sb60\sa40\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\b\cf4 Note: GPs are encouraged to attach a copy of the relevant part of the patient\loch\f0\hich\f0 \'92s care plan/s to this form.\par\pard\intbl\sa40\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 Clinical notes/ current medications (optional).\par\plain\f0\fs18\b\cf4\par\par\par\par\par\par\par\pard\intbl\qc\sa40\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par\cell\intbl\row\pard\trowd\trgaph57\trleft0\trpaddl0\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371 Eligible patients may access Medicare benefits of up to $4,250 \plain\f0\fs18\b\ul\cf4 in total\plain\f0\fs18\b\cf4  over two consecutive calendar years for dental \par services provided under items 85011-87777.\plain\f0\fs18\b   \plain\f0\fs18\cell\intbl\row\pard\trowd\trgaph57\trleft0\trpaddl0\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\b\cf4 For general enquiries about the Medicare dental items, contact Medicare Australia on 132 150.\plain\f0\fs18\cf4\cell\intbl\row\pard\trowd\trgaph57\trleft0\trpaddl0\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371 Dental practitioners should retain a copy of this referral form for record keeping and Medicare Australia audit purposes.\plain\f0\fs18\cell\intbl\row\pard\trowd\trgaph57\trleft0\trpaddl0\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18\cf4 Copies of this form and further information about this initiative are available at {\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags0}{\*\txfielddatadef\txfielddatatype1\txfielddata 68007400740070003a002f002f007700770077002e006800650061006c00740068002e0067006f0076002e00610075002f006500700063000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000}{\*\txfieldtext \plain\f0\fs18\cf4 www.health.gov.au/epc}{\field{\*\fldinst { HYPERLINK "http://www.health.gov.au/epc" }}{\fldrslt{\plain\f0\fs18\cf4 www.health.gov.au/epc}}}}\plain\f0\fs18\cf4\par Copies of the form may also be ordered by faxing: (02) 6289 7120 or phoning: (02) 6289 4297.\cell\intbl\row\pard\trowd\trgaph57\trleft0\trpaddl0\trpaddt0\trpaddr57\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat5\cellx10746\pard\widctlpar\intbl\pard\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs24\b\cf4 THIS FORM SHOULD NOT ACCOMPANY MEDICARE CLAIMS\plain\f0\fs24\cell\intbl\row\pard\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par }