Ardant

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.

Referral Type *

Specialist

Allied Health Provider

Patient Details

Surname *

Given name(s) *

DVA file number *

Date of birth *

Sun	Mon	Tue	Wed	Thu	Fri	Sat
29	30	1	2	3	4	5
6	7	8	9	10	11	12
13	14	15	16	17	18	19
20	21	22	23	24	25	26
27	28	29	30	31	1	2
3	4	5	6	7	8	9

Age

Address *

PostCode *

Email Address *

Phone Number *

Mobile Number

Card Type *

Specialist

Allied Health Provider

Accepted disabilities *

Referral To

Name

Address

PostCode

Email Address

Phone Number

Mobile Number

Provider number (if known)

Condition to be treated *

Is the patient a resident in a Residential Aged Care Facility? *

Yes

Clinical details of condition including recent illnesses, injuries and current medication, if applicable Attach additional details (if applicable)

Treatment Cycle

From 1 October 2019,new treatment cycle referral arrangements apply. under these arragements an allied health provider may treat a client for up to 12 sessions or one a year, whichever end first. At the end of 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 provider at the same time.
In Austrila's health care system, GPs are responsible for ensuring that patient care is well cooridnated and that the care provided remains relevant to the clinical needs of Patient. DVA clients should see their usual GP for treatment cycle referrals.

Period of referral Please refer to the information on the Treatment Cycle above

Other treating health providers (if relevant)

Referring Provider Details

Provider Name *

Provider Number *

Practice Name *

Practice Address *