Allied Health

Referral to Package Funded Services

What is Package Funded Services?

IPC Health Package Funded Services provide Allied Health supports that are funded by one of the following:

Medicare
NDIS
Support at Home Program (formerly known as Home Care Package)

Service availability may depend on your eligibility and our current capacity

Instructions

Please complete one form per client

This form will be sent to IPC Health - Package Funded Services team for processing

Contact: 1300 472 432

Email: alliedintake@ipchealth.com.au

Our Policies

Important information on how we keep you and your data safe can be found on our website.

If you would like to view the policies, please click the button below and our website will open on a new page.

https://www.ipchealth.com.au/our-policies/

Information for you

Find out about your rights and responsibilities and our services, and view translated brochures in your language on our website.

https://www.ipchealth.com.au/translated-brochures/

Funding

Who will be funding the service? *

NDISSupport at Home ProgramMedicare

Service Selection

Services Available

Physiotherapy – Altona Meadows, Deer Park, Hoppers Crossing, Wyndham Vale
Occupational Therapy – Home visits only for residents of Brimbank, Wyndham, or Hobsons Bay LGA
Dietetics - St Albans, Sunshine, Hoppers Crossing
Podiatry – Altona Meadows, Deer Park, Hoppers Crossing, Wyndham Vale

Please note: Service availability depends on capacity at the time of your request.

What services are you seeking? *

Physiotherapy (6 years and older)Occupational Therapy (Adult)DieteticsPodiatry

select one or more services

If the service type isn’t listed, it means it’s not currently offered under Package Funded Services.

Please contact another service provider.

Service Selection Medicare

Services Available

Exercise Physiology – Deer Park
Physiotherapy – Altona Meadows, Deer Park, Hoppers Crossing, Wyndham Vale
Podiatry – Altona Meadows, Deer Park

Please note: Service availability depends on capacity at the time of your request.

What services are you seeking? *

Exercise Physiology (11 years and older)Physiotherapy (6 years and older)Podiatry

select one or more services

If the service type isn’t listed, it means it’s not currently offered under Package Funded Services.

Please contact another service provider.

Medicare

ALERT! Medicare referrals must be from your General Practitioner (GP) under:

* Chronic Disease Management Plan (CDM)

* GP Management Plan (GPMP)

The GP will usually send the referral directly to us.

All Medicare Referrals must include:

patient Health Summary
results of any recent tests (relevant to the referral)
reason for referral

Do you have a copy of the referral? *

YesNo

Upload referral document(s) *

Browse

Please contact your GP to arrange a referral and have them send it directly to us.

They can email this to alliedintake@ipchealth.com.au (preferred)

Or fax to 03 5292 3492

Does the referral document include your Health Summary or Medical History? *

YesNo

Medical History such as current medications and conditions

Why We Ask for Your Medical History

To provide you with appropriate care, we require your medical history as part of the referral process.

You will be asked to give your consent to share this information.

If you choose not to provide it, we won’t be able to process your referral until we receive the details from you or your GP.

Can you share your Health Summary or Medical History with us? *

Yes - I'll upload a copyYes - I'll provide the information in this formNo - I'll arrange for my GP to send this

I consent to sharing this information with IPC Health for the purpose of delivering Allied Health services.
I understand this information will be stored securely and used only for care planning and service delivery *

Upload Medical History / Health Summary document(s) *

Browse

Foot Condition

ingrown toe nails
wounds on foot/feet
current or recurrent infections on foot/feet

Do any of the above foot conditions apply to you? *

YesNo

Women's Health Physiotherapy

Pelvic floor dysfunction: Urinary and fecal incontinence, pelvic organ prolapse
Pregnancy and Postpartum musculoskeletal pain
Post-Operative Care: gynecological surgeries like hysterectomies or prolapse repairs
Chronic Pelvic Pain: conditions like endometriosis and vulvodynia, (including painful intercourse)

Is the referral to treat any of the above Women's Health conditions? *

YesNo

Is the referral for a person aged 14 years or younger? *

YesNo

Parent/ Guardian Details

Why We Need Parent/Guardian Information

If the person being referred is 14 years or younger, we need the details of their parent or guardian listed as Person 1 on their Medicare card.

Parent Guardian Full Name *as it appears on the Medicare Card

Parent/ Guardian Date of Birth *

Parent / Guardian Phone *

Provide Address if different to client

Medicare Card No *10 numbers of your card

Medicare Valid to *

How is the plan managed? *

Self-ManagedPlan Managed (not including NDIA)Agency Managed (NDIA)

Who is making this referral?

Referred by

Referral Date *

Referrer Name *

Relationship to client *

I confirm that I have obtained the client’s consent to make this referral and to share their personal information for the purposes outlined in this form. *

Referrer Name *

Is the client registered on Trak? *

YesNo

Trak UR Number *

Client Details

Name *

Date of Birth *

Address *

Phone *

Email *if no email, please write n/a

Aboriginal or Torres Strait Islander (optional)

Pronouns (optional)

Gender Identity (optional)

Any other relevant information (optional)

Language

Preferred Language *

EnglishOther

Language *other than English

Interpreter needed? *

YesNoTo be confirmed

ALERT! IPC Health does not provide interpreters for package-funded services.

If you need an interpreter, please arrange one through your care package or with help from a family member or friend.

Interpreter options by funding type:

Medicare – You’ll need to organise your own interpreter.
Home Care Package – Your package may cover interpreter services. Please check with your Case Manager.
NDIS – Interpreter support may be included. Please speak with your Support Coordinator.
Support at Home Program – Interpreter services may be available. Please discuss with your Case Manager.

Medical Information

Why We Ask for Your Medical Information

To ensure we deliver safe and effective services, you may provide relevant health information you'd like us to be aware of.

E.g. current medications, diagnoses, allergies, risks, mobility needs

This helps our team tailor supports appropriately.

Sharing this information with IPC Health is for the purpose of delivering supports as outlined in this agreement.

Can you share your Health Summary or Medical History with us?

Upload document(s) *

Browse

Health Summary / Medical History

Current Medications *If none, write n/a

Allergies *If none, write n/a

Chronic Conditions - please select any of the conditions below that apply to you

Chronic Musculoskeletal

Back painOsteoarthritisRheumatoid arthritisOsteoporosis

Mental Health

Anxiety disordersDepression

Chronic Respiratory

AsthmaChronic obstructive pulmonary disease (COPD)

Cardiovascular

Hypertension (high blood pressure)Coronary artery diseaseHeart failureStroke

Neurological

DementiaParkinson’s diseaseEpilepsy

Cancer

Past diagnosis of cancerCurrent diagnosis of cancer

Chronic Endocrine and Metabolic

Pre-diabetesType 1 diabetesType 2 diabetes (insulin dependent)Thyroid disorders

Other

Chronic kidney diseaseHearing lossVision impairmentSkin conditions (e.g., psoriasis, eczema)

Any other Chronic Condition not listed above

Daily Living & Mobility

Do you currently use any of the following?

Do you need help with any of the following daily tasks?

Do you experience any of the following?

Other

Representative Details

If you have a representative, please provide their details.

Eg, partner, parent, spouse, carer, guardian, child

Representative Name

Relationship to client

Representative Phone:

Representative Email:

Support at Home Program Provider Details

Please provide as much information as possible

Provider Organisation / Company Name *

Home Care Package Level

Support at Home Provider Organisation / Company *

Support at Home Classification

Care Partner Name

Care Partner Phone

Care Partner Email

Email Address for invoices

NDIS Details

Please provide as much information as possible

Participant Number *

Plan Start Date

Plan End Date

Please provide the number of hours funded under your NDIS plan (optional)

NDIS Plan Upload (optional)

Browse

Support Coordinator Details

Please provide details if applicable

Support Coordinator Name

Organisation / Company Name

Support Coordinator Phone

Support Coordinator Email

NDIS Plan Manager

Plan Manager: {{ndis payer}}

Plan Manager Organisation / Company Name *

Email address for invoices *If you aren't sure of the email address for invoices, please write 'to be confirmed'

Agency Managed (NDIA)

IPC Health will upload invoices to the NDIS provider portal

Podiatry

Podiatry is available in clinic only at the locations listed

Podiatry Preferred Clinic *

Altona MeadowsDeer ParkHoppers CrossingWyndham Vale

How often would you like the service?

Podiatry - GeneralPlease select one or more

Reason for Referral / Extra Information

Occupational Therapy

Occupational Therapy is only available for at home service in selected Local Government Areas.

Please select your LGA (Local Government Area) *

BrimbankWyndhamAltona Meadows

OTPlease select one or more

Reason for Referral / Extra Information

Exercise Physiology

Preferred Service Location *

In ClinicAt Home

Preferred Clinic *

Hoppers Crossing

How often would you like the service?

Exercise Physiology ServicePlease select one or more

Reason for Referral / Extra Information

A 1:1 assessment with an Exercise Physiologist is required to confirm suitability for group sessions.

Physiotherapy

Preferred Service Location *

In ClinicAt Home

Preferred Clinic *

Altona MeadowsDeer ParkHoppers CrossingWyndham Vale

How often would you like the service?

Reason for Referral / Extra Information

A 1:1 assessment with a Physiotherapist is required to confirm suitability for group sessions.

Dietetics

This service is available on a case by case basis - based on clinician availability at the time of service request

Preferred Service Location *

In ClinicAt Home

Preferred Clinic *

St AlbansSunshineHoppers Crossing

Dietetics Supports

Nutritional assessmentDietary Support

Reason for Referral / Extra Information

Key Contact to arrange Service Agreement

Other (please provide details)

Do you want a copy of this referral?

Would you like a copy of this referral emailed to you? *

YesNo

Please provide your email address *

Save and Complete Later