Online Client Application: Chronic Care/EPC Medicare Clients

Your Details

Name*

First Last

Address*

Street Address Address Line 2 City State Postcode

Mobile*

Work Phone

Email*

Enter Email Confirm Email

Date of Birth*

Referring Health Professional (eg Doctor) Details:

Referring Health Professional Name:*

Referring Health Professional Address*

Street Address Address Line 2 City State Posrcode

Referring Health Professional Email

Please attach your Medicare Referral Form*

The referral form must be titled Referral form for Individual Allied Health Services under Medicare for patients with a chronic medical condition and complex care needs.
An example of the form can be found here

Please confirm your form states the following information:*

Select All
Your GP name, address and provider number
Addressed to Sport & Spinal Physiotherapy or Your Podiatry Canberra
States the number of services for each type of Allied Health Service
Signed and dated by your GP

Please note: If any of the above details are missing from your form, you will need to return to your GP to amend your form

Declaration

I understand and acknowledge that:*

The above information is true to the best of my knowledge
I will at all times be responsible for payment of my account in full
I will need to provide payment of my account in full at private rates at the time of consultation until I have provided all of the information and documents required

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