Diabetes: Living Better and Stronger Program Enrolment Form
Website: http://www.wnswphn.org.au/carepartnership-diabetes

Send Form via Argus ONLY to: WNSWLHD-ccdubconnectcare@health.nsw.gov.au

The Diabetes - Living Better and Stronger Program aims to improve access and deliver better health care for people living with Type 2 Diabetes (T2DM) in Western and Far West NSW.
This program is a partnership between four organisations: Western NSW Local Health District, Far West Local Health District, Western NSW Primary Health Network and Rural Doctors Network. The partnership enables us to improve your diabetes care support anywhere across the health system (e.g., GP practice, Aboriginal health service or hospital) by coordinating and increasing access to diabetes services	
PATIENT’S INFORMATION	
Your patient’s name: <<Patient Demographics:Full Name>>	
Date of birth: <<Patient Demographics:DOB>>	AUID (if known):	
Address: <<Patient Demographics:Address>>	Phone: <<Patient Demographics:Phone (Mobile)>>	
Medicare No: <<Patient Demographics:Medicare Number>>	Town: <<Patient Demographics:Address Preferred City>>	
Medicare Expiry date: <<Patient Demographics:Medicare Expiry Date>>	Medicare card reference No: 	
Patient identifies as: <<Patient Demographics:Ethnicity>>	
Country of birth:  <<Patient Demographics:Country of Birth>>   	Preferred language: <<Patient Demographics:Language Preferred>>	
Consent Obtained for Enrolment and Information Sharing (see reverse):	Yes		No	
CONSENT FORM SUBMITTED BY: 	
GP/health professional: <<Doctor:Name>>	Phone: <<Doctor:Phone>>	
General Practice / ACCHS / LHD: <<Practice/Location:Name>>	
Email: <<Doctor:E-mail>>	
REASON FOR ENROLMENT (ANSWER ALL WITH YES OR NO)	
Hba1c above 7% or GP clinical judgment <<Hba1c above 7% or GP clinical judgment>>
Comorbid conditions (please list)
………………………………………………………………………………………………………………
At risk of hospital unplanned Emergency presentation & admission due to T2DM self-management/ has had multiple hospital presentations <<At risk of hospital unplanned Emergency presentation & admission due to T2DM self-management/ has had multiple hospital presentations>>
Requiring a multi-disciplinary & collaborative team approach <<Requiring a multi-disciplinary & collaborative team approach>>
No regular General Practice or management team for T2DM <<No regular General Practice or management team for T2DM>>
Others, please specify ……………………………………………………………………………………	
PARTICIPANT INFORMATION	
•	Your GP/Health Provider has recommended linking you to the Diabetes: Living Better and Stronger Program. 
•	By filling in this form you are agreeing to be linked to the Diabetes: Living Better and Stronger Program. Your name and details above will be entered in the Local Health District electronic record management system. This is the only time that your personal information is shared. 
•	General information about how many people are using the program and how it is contributing to the health outcome of people living with diabetes will be reported to the Ministry of Health and to the partners to make improvements in the program. 
•	Your health information will remain private and confidential and you will not be personally identified in this evaluation and reporting.  
•	Your GP or health care provider will discuss your care and any referrals to services with you. This information is private and confidential and your personal details will not be shared with the program. 

YOUR CONSENT TO PARTICIPATE IN PROGRAM	
I have been informed of the services and care provided as part of the Diabetes: Living Better and Stronger Program <<I have been informed of the services and care provided as part of the Diabetes: Living Better and Stronger Program>>
I consent to share my details for the purposes of participating in this program <<I consent to share my details for the purposes of participating in this program>>
You can withdraw your participation and consent to be involved in this program at any time by contacting your GP. Your GP will contact the Diabetes: Living Better and Stronger program to withdraw your consent.	
YOUR CONSENT TO SHARE INFORMATION FOR RESEARCH 	
There is the opportunity for us to learn about what works best for rural communities through research. Your information remains private, and you would not be personally identified in this process. You can consent for the participation to this research below and participation in this is voluntary and will not affect your participation in the program in any way. 
Any research would be approved first by Greater Western Human Research Ethics Committee to protect our community, including approval by the Aboriginal Health and Medical Research Council.  

I consent to diabetes specific health information that does not identify me to be used in diabetes-related research that have ethical approvals from relevant Ethics Committees <<I consent to diabetes specific health information that does not identify me to be used in diabetes-related research that have ethical approvals from relevant Ethics Committees>>
I am willing to be contacted by the program team for feedback on my experience? <<I am willing to be contacted by the program team for feedback on my experience?>>
If yes what is your preferred contact?  <<If yes what is your preferred contact?>>
Contact:__________________________________________________________________________                                                     
Do you have a carer (i.e., someone such as a family member, friend or social worker who regularly cares for your health and physical needs)? <<Do you have a carer (i.e., someone such as a family member, friend or social worker who regularly cares for your health and physical needs)?>>
Would you and your carer be happy to be contacted about their experience of their caring role?  <<Would you and your carer be happy to be contacted about their experience of their caring role?>>
If yes, please fill in their details below:
Name:	<<If yes, please fill in their details below: Name>> Preferred contact details: <<If yes, please fill in their details below: preferred contact >>

You can withdraw your participation and consent to be involved the diabetes-related research at any time by contacting your GP. This will not affect your participation in the program. 	
Patient Name/OR Person consenting on behalf of the patient:

Date: <<Miscellaneous:Date>>

Relationship of Person consenting to individual:

GP / Health Professional Name: <<Doctor:Name>>	               Date: <<Miscellaneous:Date>>

Patient Name:<<Patient Demographics:Surname>>, <<Patient Demographics:First Name>> DOB: <<Patient Demographics:DOB>>
Recipient: <<Addressee:Name>> Date of Report: <<Miscellaneous:Date>>