DVA Referral 	

This form is for Referral only. If you are seeking prior approval for treatment of a veteran, use Form D1328 - Treatment Prior Financial Approval Request Form.
All information requested on this form must be provided.
Please complete the patient's details, including address and date of birth if file number is not known. This form should be used by the referring provider to:
• refer directly for treatment services
• refer directly to another provider where prior approval from DVA is not required.
For detailed information on DVA's prior approval and other administrative requirements, please refer to the booklet 'Notes for GPs', 'Notes for Allied Health Providers - Section One - General' or contact DVA by phone.
Where bulk referral is appropriate, please send any necessary clinical details directly to the provider. 
The GP is responsible for checking the eligibility of patients to receive treatment at DVA expense.White card holders are entitled to receive treatment at DVA expense for their accepted disabilities only.
DVA will not be responsible for costs incurred where prior approval requirements are not followed, where ineligible patients are treated, or where a patient is treated by a provider who is not authorised to provide treatment on behalf of DVA.
If an indefinite referral to a medical specialist is appropriate for a chronically ill patient, the period of referral may be noted on the form as "ind". Note this is not applicable for referrals to Allied Health Providers, see information on the Treatment Cycle on page 2.

1. Referral Type:         <<Referral Type >>       	

Patient Details:	

2. Surname	<<Patient Demographics:Surname>>	
3. Given name(s)	<<Patient Demographics:First Name>>  <<Patient Demographics:Middle Name>>	
4. DVA File number	<<Patient Demographics:DVA Number>>	
5. Date of birth	<<Patient Demographics:DOB (long)>>	
6. Address	<<Patient Demographics:Full Address>>	
7. Email address	<<Patient Demographics:E-mail>>	
8. Phone Number	H: <<Patient Demographics:Phone (Home)>>   M: <<Patient Demographics:Phone (Mobile)>>	
9. Card Type 	<<DVA Card type?  >>	
10. Accepted disablities	<<Accepted Diasbilities?>>

11. Referral To:	

Name: 	<<Addressee:Name>>	
Address	<<Addressee:Full Address>>	
Email Address	<<Addressee:E-mail>>	
Phone number: 	<<Addressee:Phone>>   	
Provider Number: 	<<Referree's Provider number (if known)?>>	

12. Condition to be treated?
<<Condition to be treated?>>

13. Is the patient a resident in a Residential Aged Care Facilit?y	<<Is Pt. a resident of a Resdential Aged Care Facility?>>	
                                                          Level of Care	<<Level of care?>>	
Date funding began	<<Date funding began?>>	

14. Clinical details of condition including recent illnesses, injuires and current medication, if applicable: (Attached additional details if applicable) 

Past History:
<<Clinical Details:History List>>

Medication:
<<Clinical Details:Medication List>> 

Other: 

Treatment Cycle 
From 1 October 2019, new treatment cycle referral arrangements apply. Under these arrangements an allied health provider may treat a client for up to 12 sessions or one year, whichever ends first. At the end of the treatment cycle the allied health provider must report back to the client's usual GP. If further sessions are clinically necessary, the usual GP may provide the client with another referral for an additional 12 sessions. 
Clients may have as many treatment cycles as their usual referring provider determines are clinically necessary. They may also have treatment cycles with multiple types of allied health providers at the same time. 
In Australia's health care system, GPs are responsible for ensuring that patient care is well coordinated and that the care provided remains relevant to the clinical needs of the patient. DVA clients should see their usual GP for treatment cycle referrals. 

15. Period of referral
Please refer to the informaiton on the Treatment Cycle above	<<Period of Referral?>>	

16. Other treating health providers (if relevant)	<<Provide details of other  treating health Providers ?>>	

Referring provider details 	

17. Provider Name: 	<<Doctor:Name>>	
18. Provider Number: 	<<Doctor:Provider Number>>	
19. Practice Name: 	<<Practice:Name>>	
20. Practice Address:	<<Practice:Address>>	
21. Email address:	<<Practice email address?>>	
22. Phone Number:	Ph: <<Practice:Phone>>
Fax: <<Practice:Fax>>	

Provider Signature: 	Date: 
<<Miscellaneous:Date (short)>>	

Allied Health Providers should retain this referral form for record keeping and Department of Veterans' Affairs audit purposes.