After Hospital Home Care Referral Form

After Hospital Home Care Program (AHHC)

Ph: 1800 054 300 Email: home@amplarhealth.com.au

Referral Details

What is the clinical reason for initiating this referral? *

Hospital Name *

Expected Discharge Date *

Patient Details

Title *

Surname *

Given Names *

Date of Birth *

Address *

Suburb *

Postcode *

Health Fund *

Health Fund Membership Number *

Gender *

Phone Number *

Email

NOK Name

NOK Phone Number

Consent & Referrer Details

I confirm I have informed the patient and obtained their consent that:
A: Their personal information (including health information) will be shared with Amplar Home Health for the purpose of providing at home services ("Service").
B: Amplar Home Health will contact the patient about the Services and their nominated Next of Kin if Amplar Home Health has not been able to contact the patient after three attempts. The Next of Kin will be asked to get the patient to call Amplar Home Health to discuss next steps.
C: If applicable, Amplar Home Health may be required to disclose their personal information to their health fund, or their health fund's authorised agency(ies) to ascertain eligibility for the Services, confirm receipt of Services and facilitate their participation in the Services. All parties involved with this program are bound by strict obligations of confidentiality and privacy. *

Referral Source *

At the time of referral, Is the patient pre-hospital admission or post hospital discharge *

Is this patient currently active on an Amplar Preventative program *

Please specify which program: *

Referrer Name *

Referrer Email Address (for communications) *

Usual GP Name

Usual GP Practice

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