Disability referral

If you would like to refer your client for disability support services, please use the following link to submit your referral.

Disability referrals

Home care referral

If you would like to refer a client or patient following a hospital visit, please complete the form below.

Funding Type(Required)

DVA Card Number(Required)

Claim Number(Required)

Health Fund(Required)

Member Number(Required)

NDIS Participant Number(Required)

Client currently receiving DVA funded services

Yes

Provider Name

Patient Details

Patient First Name(Required)

Patient Last Name(Required)

Street Address(Required)

Suburb(Required)

Postcode(Required)

State(Required)

Patient Phone Number(Required)

Patient Email Address(Required)

Patient Date of Birth(Required)

Next of Kin First Name(Required)

Next of Kin Last Name(Required)

Next of Kin Phone Number(Required)

Next of Kin Email Address

Referral Details

Are you making this referral on behalf of a hospital? (Required)

Yes

What is your role?(Required)

Please specify(Required)

Date of Referral(Required)

Referrer First Name(Required)

Referrer Last Name(Required)

Referrer Phone Number(Required)

Referrer Email Address(Required)

Referring Practice/Clinic Name

Ward(Required)

Date of Hospital Admission(Required)

Diagnosis(Required)

Do you know the date of first visit? (Required)

Yes

No, to be confirmed

Date of First Visit(Required)

Who is your provider? (Required)

Hospital Provider

GP Provider

Consultant Provider

Hospital Provider Number

Consultant Provider Number

Next OPD Date

General Practitioner (GP) Details

GP First Name

GP Last Name

GP Phone Number

GP Email Address

Name of GP Practice/Clinic

GP Provider Number

Treatment Request

Wound Management

Post-surgical

Ulcer

Traumatic

Other

Wound Management Details

The medication authorisation form is required to be completed prior to your first visit. Please click here to download a copy of the form.

Have you completed the medication authorisation form?

Yes

Please upload the Medication Authorisation Form

Max. file size: 64 MB.

Please email your completed medication authorisation form to clinicalcareinfo@kandacare.com.au or fax (add number) prior to the first visit.

Medication Management Details

Continence Assessment/Management Details

Stomal Therapy Details

Palliative Care Details

Personal Care Assistance Details

Domestic Assistance Details

Occupational Therapy Assessment Details

Speech Therapy Details

Physiotherapy Details

Podiatry Details

Details

Additional Information

Notes

CAPTCHA

NDIS

Disability Services

Funding Streams

Home Care Services