Allied Health Referral Program | Encompass Health Services

Client Identifiers

Name*

First Last

Email Address for Correspondence- A Copy of this referral form and any document will be sent to this address for your records.*

Client Preferred Phone*

Date of Birth*

Preferred Communication for Brief Messages*

Mobile Text

Voicemail

Client Address*

Street Address City State Post Code

Funding / Invoice Details (Card payments welcome - Surcharge Applies) Please see below for Private Payment options

Is this referral relating to Medico Legal Issue*

Yes

Health Insurance/ Home Care Package / NDIS Plan*

Yes

NDIS Plan Dates : Start and Finish - If known

NDIS Participant Number: #

NDIS Plan Type please check whichever is applicable

Plan Managed

NDIA

Self Managed

Not Applicable

NDIS Hours required - please stipulate hours of funding available in the participant plan for each required therapy (this enables us to produce a Service Agreement (SA) for the Participant) Please be aware that an OT FCA usually requires SA of a minimum of 15 hours including, face to face and non face reporting. We only charge for the time that is actually used. All other therapies are dependent on conditions. SIL assessments are of a complex nature and usually require 20 hours minimum for the report completion.

If "plan managed", please provide company and contact details including email for invoices)

Please advise nominee for signing service agreements and/or authority to act on behalf of participant.

NDIS - Major Modifications - Please note If Major modifications are being sought, please supply summary details.

Service Agreements and general NDIS information and Consent - who is your authorised signatory and their preferred contact method for documents? - (If Applicable)

NDIS Support Coordinator - if applicable

Home Care Package (HCP) Level

HCP Payment details for invoicing including Purchase Order Number - Email or Portal

HCP Provider / inc Capital Guardian

Referrer Details

Referrer Organisation*

Referrer Contact Name*

First Last

Referrer Email*

Referrer Phone

Referrer Address

Street Address Address Line 2 City State Post Code

Specific Referral Details

Presenting Conditions or current medical history - as applicable*

Is NDIS Plan, Patient Health Summary or MAC Plan available? Please attach relevant documents. (This is helpful to plan services)

Report Frequency - If a written report is required, please indicate the frequency you would like. As a standard we provide a written report after an Initial Consultation and thereafter, as required. (This may attract an additional charge depending on the time required to produce it.)

Treatment Request - Therapies required - It is really helpful for our Therapist to know specifically what RECOMMENDATIONS you are looking for to prioritise their assessment, treatment*

NDIS GOALS If you have goals you can share at this time please include them here

Therapies required*

Urgency of request for services (Usually within 14 days of initial contact)*

Private Payment Options - If you choose directly depositing payment method instead of card payment, we require a 50% deposit into our account prior to your appointment time and date. ***** • Encompass Health Services Pty Ltd *****BSB: 014672 Ac: 417992957 *****Terms: 7 days for accounts issued after the appointment

Sunshine Coast EHS Referrals Program

If you would like to make a EPC, CDM OR DVA referral, please choose one of the following forms:

For all other referrals, please fill the form below:

For all referrals, please fill the form below:

Client Identifiers

Funding / Invoice Details (Card payments welcome - Surcharge Applies) Please see below for Private Payment options

Referrer Details

Specific Referral Details

Encompass Health Services

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Encompass Health Service