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Travel referral (Form B)

Travel referral (Form B)

Travel referral (Form B)

Section A - Patient details

(patient or referring clinician to complete)

Has the patient's details changed?
Date of birth * (DD / MM / YY)
Expiry date * (MM / YY)
Are you of Aboriginal and/or Torres Strait Islander origin?
Section B - Referral details

(patient or referring clinican to complete with details of treating specialist)

Travel referral is valid for 12 months (subject to review at any time)

(include reason for referral)
Is this the patient's closest specialist?
Section C - Reason for travel

(referring clinican to complete)

If available, has telehealth been considered for this appointment?
Appointment is for
Appointment type: Admission
Appointment type: Outpatient
This condition may require ongoing travel for appointments?
Clinically recommended mode of travel
for charter flights only
(based on patient's circumstances)
Clinical reason for selected mode of travel
Section D - Accommodation

(referring clinican to complete)

Is the patient applying for a subsidy for accommodation*?
(e.g. clinical reason to stay after appointment or discharge date, accommodation preference, etc.)

*As per the eligibility criteria. Approved by Hospital and Health Service.

Section E - Patient escort details
Is the patient applying for a Patient Escort*?
Date of birth * (DD / MM / YY)
Does the patient escort require accommodation?

*As per the eligibility criteria. Approved by Hospital and Health Service.

Section F - Declaration

Referring clinician (or clinicians nominated representative) declaration:

I certify that the information provided on this form is correct. I have advised the patient or guardian / carer that Hospital and Health Service staff may contact the referring facility and travel / accommodation providers regarding this referral.

Date * (DD / MM / YY)
Hospital and Health Service use only - Approval
Subsidy approved for travel to
Mode of travel to
Patient escort approved
Accomodation approved
Accommodation approved
Has it been determined if a telehealth alternative exists for this patient?
Date (DD / MM / YY)
Date (DD / MM / YY)