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{\footerf\pard\plain\f0\fs24\par}\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx7920\plain\f1\fs36\b Team Care Arrangements (723)\par\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs16 NB: Use the tab key or mouse to move through the form\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs20\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b\ul Patient Name\plain\f1\fs20  \par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Patient Demographics:Full Details>>{\*\txfieldend}\plain\f1\fs20\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b\ul Date:\plain\f1\fs20  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Miscellaneous:Date>>{\*\txfieldend}\plain\f1\fs20\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b\ul Doctor coordinating Team Care Arrangement\plain\f1\fs20  \plain\f1\fs18 (who is the doctor who prepared the GP Management Plan if relevant)\par\plain\f1\fs20 Informed consent has been obtained to coordinate this Team Care Arrangement.\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs18 <<Doctor:Name>>{\*\txfieldend}\plain\f1\fs20\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs24\b\ul Eligibility\plain\f1\fs20\b  \plain\f1\fs20 Team Care Arrangements may only be provided for patients with one or more chronic conditions and complex health care needs requiring a multidisciplinary care team. The reason/s I believe this patient is eligible are: \cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs24\b\ul Patient Assessment\plain\f1\fs20\b  \plain\f1\fs20 that considers current and future health care needs: \cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080  \par\plain\f1\fs24\b\ul Providers \par\plain\f1\fs16\b\ul\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs20\b Provider \plain\f1\fs20 (\plain\f1\fs18 and description)            \plain\f1\fs20\b Provider's input into care plan\plain\f1\fs20                 \plain\f1\fs20\b Provider's specific actions/roles\plain\f1\fs20  \cell\intbl\row\pard\trowd\trgaph108\trleft0\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2552\clvertalt\cellx5954\clvertalt\cellx9621\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\cell\intbl\row\pard\trowd\trgaph108\trleft0\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2552\clvertalt\cellx5954\clvertalt\cellx9621\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\cell\intbl\row\pard\trowd\trgaph108\trleft0\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2552\clvertalt\cellx5954\clvertalt\cellx9621\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\cell\intbl\row\pard\trowd\trgaph108\trleft0\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2552\clvertalt\cellx5954\clvertalt\cellx9621\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 The providers have consented to these actions/roles. Two way communication has taken place between {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Doctor:Name>>{\*\txfieldend}\plain\f1\fs20  and each provider by either one or more of the following: a face to face meeting, telephone or video-link conversation, or two way exchange of e-mails or faxes. (The two way communication between a GP and a pharmacist as part of an HMR can be used as a providers input into the TCA.)\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs24\b\ul Management Goals\plain\f1\fs20\b  \plain\f1\fs20 made in collaboration with the patient \cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs24\b\ul Arrangements made\plain\f1\fs20\b  \plain\f1\fs20 for giving the treatment, services, and care to achieve the management goals\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs24\b\ul Actions to be taken by patient\plain\f1\fs20  \cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs24\b\ul Other services and care\plain\f1\fs20\b  \plain\f1\fs20 that the patient may need or already has\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b\ul Relevant examination\plain\f1\fs20  \par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Summary:Progress Notes (Selected)>>{\*\txfieldend}\plain\f1\fs20\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b\ul Relevant investigations\plain\f1\fs20  \par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Summary:Investigation Results (Selected)>>{\*\txfieldend}\plain\f1\fs20\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Doctor:Name>>{\*\txfieldend}\plain\f1\fs20  has explained the purpose of the Team Care Arrangement and I give permission to coordinate and discuss my medical history and diagnosis with the Providers listed. All participants to retain confidentiality. I am aware that there is a Medicare fee for the preparation of this Team Care Arrangement and that there may be fees for other Providers.\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\trowd\trgaph108\trleft0\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx4111\clvertalt\cellx7761\clvertalt\cellx9636\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b Patients Signature\plain\f1\fs20 :\plain\f1\fs20\b\ul\cell\plain\f1\fs20\b Patients Name \plain\f1\fs20\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Patient Demographics:Full Name>>{\*\txfieldend}\plain\f1\fs20\par\plain\f1\fs20\b\par\cell Date:\plain\f1\fs20\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Miscellaneous:Date>>{\*\txfieldend}\plain\f1\fs20\b\par\cell\intbl\row\pard\trowd\trgaph108\trleft0\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1702\clvertalt\cellx9651\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b\ul Review date\plain\f1\fs24\b :\plain\f1\fs20\cell\cell\intbl\row\pard\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par }