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Privately Paid Allied Health Online Referral

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Participant Information

Origin
Interpreter required
Communication preferences or requirements
Access requirements

Advocate and Guardian Information

Does the participant have

Referrer Information

Services Required

Division

Diagnosis and Background

Documentation

Please provide a copy of any relevant previous allied health and medical reports, if available.

Click or drag files to this area to upload. You can upload up to 25 files.
Accepted file types: .xlxs, .jpg, .jpeg, .doc, .docx, .pdf, .png

Risks and Safety

Are there any court orders or legal proceedings applicable, e.g. child custody?
Has the participant ever been physically aggressive towards allied health, medical or support staff?
Has the participant been incarcerated in a prison, juvenile detention centre or spent time in a forensic hospital for a violent or sexual offence?
Is the participant currently engaging in alcohol or drug use?
Are there any known risks for visiting the participant in their own home?

Initial Assessment

Location of initial appointment
Are there any preferences for a consultant?
Appointment reminders

Service Agreement

Who will sign the service agreement

Payment Method

Who does ORS invoice?
In addition to the payment provider, would you or another party (e.g. advocate) like to receive the invoices?
Do you need a quote for service prior to proceeding?
Do you need a certain reference number or specific information on the invoice (e.g. PO number)

Further Information

Disclaimer

If you require assistance completing this referral, you can lodge an enquiry online, call us on 1800 000 677 or email our Intake Team.


Please note:  We endeavour to process referrals within 2 business days and will call you to schedule an appointment. If we are unable to make contact by telephone, we will schedule the appointment and email this to the contacts provided in this referral form. This email will confirm the appointment date and time, and any additional documentation or information required prior to the appointment. We would appreciate you looking out for this email and letting us know as early as possible if it needs to be rescheduled.

If your referral is urgent, please call us on 1800 000 677.


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