Get Electronic Medical Referral

Filling out an Electronic Medical Referral can be a straightforward process when you understand each component of the form. This guide provides a clear, step-by-step approach to help you effectively complete the referral online.

Follow the steps to fill out the Electronic Medical Referral online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing the details of the person being referred. Enter their full name, date of birth, and address in the respective fields. Make sure to include accurate contact information such as the telephone and mobile numbers.
3. Specify the gender of the person by selecting the appropriate option: female or male.
4. Enter the medical card number if it is required for the referral process to proceed.
5. Indicate whether the person has additional needs, such as requiring wheelchair access, by selecting 'yes' or 'no'.
6. Next, fill in the referrer details. Provide your name, the primary care team area, and your address. Include your telephone and fax numbers as well.
7. Sign the form to acknowledge your role as a referral agent and enter your job title along with the date.
8. If applicable, provide details of the GP, including their name, primary care team area, address, and contact numbers.
9. In the medical history section, detail any relevant medical history, current medication, and previous attendance at mental health services or counseling.
10. In the reason for referral section, clearly outline the symptoms, their duration, impact on daily functioning, and any additional difficulties being experienced.
11. Indicate if the person has agreed to work on their psychological problems and is willing to attend counseling.
12. Document if the person has been referred to any other agency and provide relevant names and dates of birth for any relatives referred to CIPC.
13. Include any other information that may be pertinent to the referral.
14. For the CIPC client opt-in section, confirm whether you have given the client the CIPC Information Leaflet and specify how clients can be contacted by selecting appropriate options.
15. Once you have completed all fields, save your changes, and consider downloading, printing, or sharing the completed form as needed.

Start filling out your Electronic Medical Referral online today!