<p> Service provider information update</p><p>Completing and returning the form Please complete the form below providing accurate details of your service for inclusion in the HealthPathways site and in our consumer awareness campaign. Fields marked with an asterisk (*) are mandatory.</p><p>You may edit the document directly or write your answers on a printed copy, then return via email to [email protected] OR request that the consultant make a 10-minute appointment with an appropriate contact person to take the details over the phone (this is the quickest and easiest option).</p><p>Please note:  All service providers must complete Parts A and B  Do not complete Part C unless your service is offered through a multidisciplinary setting  Do not complete Part D unless you receive referrals from other services/ practitioners)</p><p>A note for multidisciplinary settings: many practices offer more than one type of service, for example a General Practice may also offer a part-time Teen Health clinic or a Psychology service. </p><p>Although much of the contact information between the services will be identical, important details such as referral procedures and criteria for inclusion will differ and therefore require individual entry into the HealthPathways system. </p><p>If your facility offers more than one type of service, a separate update form must be completed for each service offered (in this instance, please advise the consultant as this information can be collected and duplicated quickly via a telephone call rather than completing multiple sets of paperwork).</p><p>PART A: SERVICE DETAILS Display name * (name of service or practitioner)</p><p>Service Type * □ General Practice □ Allied Health □ Pharmacy □ Residential Aged Care Facility □ Specialist Practice (please specify) ……………………………... □ Hospital Based Service □ Midwifery Service □ Diagnostic Service □ Community Service (please specify) ……………………………. □ Other (please specify) ………………………………………………….</p><p>Service description/ note * (please provide a short paragraph that describes the nature and purpose of the service) Additional services provided (eg. general practice care, diabetes checks, family planning, health assessments, mental health assessments, pap smears, asthma reviews, diving and aviation medical assessments, travel vaccinations, home visits available on request, etc.)</p><p>HPI-O/ HPI-FAC * (please provide health provider ID number if applicable) </p><p>Funding model * □ Public □ Private</p><p>Service billing options: □ No Fee Additional information- □ Fee optional (please tick all that apply) □ Bulk billing only □ Fees and bulk billing □ Co-payment □ Other</p><p>Criteria * (e.g. patient is a NSW resident or presents with a particular condition as listed in service description)</p><p>Exclusions </p><p>Appointment required * □ Yes □ No</p><p>Priorities & urgent □ Yes □ No appointments * (are any particular If yes, what are the conditions for priority? patients or conditions given priority? Who? What is the process for a referring practitioner or for a patient requiring an urgent appointment? Include details of If yes, what is the process? drop-in clinics, teen clinics, etc.)</p><p>Online booking system □ Yes □ No available * (e.g. existing patients can If yes, briefly describe process: book via Appointuit app)</p><p>Advice available by phone * □ Yes □ No</p><p>After Hours * □ Yes □ No (Does your service have existing arrangements for patients to access care in If Yes, briefly describe arrangements (how the service is the after hours’ period?) provided and at what times):</p><p>Telehealth arrangements * Our practice is equipped to offer telehealth (video based consultation) consultations □ Yes □ No Our practice currently offers telehealth consultations: □ Yes □ No If Yes, please describe your telehealth service (e.g. the system you use and how other health services can arrange appointments with you):</p><p>Telehealth software utilised * □ Skype □ Vidyo (if applicable) □ Lync □ WebEx □ Consult Direct □ other (please specify)</p><p>……………………………………….</p><p>Sub-region(s) covered by □ Cooma & Snowy Mountains service * (tick all that apply) □ Bombala & Delegate □ Eurobodalla □ Far South Coast □ Goulburn & Crookwell □ Queanbeyan region & Yass □ All Southern NSW □ ACT</p><p>Internal notes (e.g. wait list estimate)</p><p>Opening hours * Day Open Close (please provide regular opening hours, Monday with an additional note for any Tuesday irregularities e.g. visiting specialist one Thursday per month or service open one Wednesday Sunday per month on rotating roster with Thursday other local pharmacies, etc.) Friday Saturday Sunday Other (please specify) Accessibility elements and □ Translator/ interpreter service other facilities available * □ Braille signage (tick all that apply) □ Hearing induction loop □ Accessible telephones □ TTY facilities (hearing aid compatible) □ Accessible toilets □ Public toilets □ Parking- free □ Parking- paid □ Parking- suitable for seniors □ Disability parking □ Wheelchair accessible □ Baby change facility □ Parents’ room □ Other (please specify) …………………………………………………….</p><p>PART B: SERVICE CONTACT DETAILS Contact person *</p><p>Position held by contact person *</p><p>Street Address *</p><p>Postal Address *</p><p>Suburb/ Town *</p><p>Postcode *</p><p>State *</p><p>Phone *</p><p>Fax *</p><p>Email *</p><p>Website *</p><p>PART C: FACILITY CONTACT DETAILS (Note: only complete this section where facility details differ from service contact details i.e. if service is offered from a multi-disciplinary setting such as a Community Health Centre) Name of facility / centre Facility/ Site description (e.g. the facility has 2 treatment rooms, 5 consulting rooms and 2 practice nurses. There is free parking at the rear of the building and building contains a GP, dietitian and psychologist)</p><p>Facility contact person</p><p>Position held by contact person</p><p>Street address</p><p>Postal address</p><p>Suburb / Town</p><p>Postcode</p><p>State</p><p>Phone </p><p>Fax</p><p>Email</p><p>Website</p><p>PART D: REFERRAL DETAILS Accepts e-referrals * □Yes □ No</p><p>Accepts telephone referrals * □Yes □ No If yes, referral phone number is ...………………………………………. Acute referral phone number (if applicable) ……………………...</p><p>Accepts fax referrals * □Yes □ No If yes, referral fax number is ………………………………………….....</p><p>Accepts email referrals * □Yes □ No If yes, referral email address is ………………………………………….</p><p>Accepts web referrals * □Yes □ No If yes, web referral url is …….……………………………………………. Referral form * (please insert referral form download url or attach file) Agree to terms: □ I consent to practice details contained herein to be updated on COORDINARE’s contact database □ I consent to practice details contained herein to be incorporated into the localised HealthPathways condition-based database and service directory (note that currently HealthPathways is available solely for practitioner use, however a consumer portal is in development that may contain some of the service details contained herein) □ I would like information on how to update contact details on the National Health Service Directory □ I would be interested in further information/ training on telehealth initiatives</p><p>Contact details: Please provide the most appropriate contact details for follow-up by the HealthPathways content team. This information will not be included on the HealthPathways site and is used for our internal validation purposes only. </p><p>Name of contact person completing this form:</p><p>Position held: Date:</p><p>Preferred contact method: □ Phone □ Email </p><p>Please complete and return this form via email to: [email protected]</p>