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NHealthscope Nl I=ATFI stscY I m portant I nformation for Patholoqy Col lectors 1. Patient must present with a new-signed referral for every series of tests covered by Rule 3 Exemption. 2. Advise patient before expiry of current Rule 3 Exemption referralthat a new-signed form is needed from Doctor if he/she wishes to refer patient for further tests under this provision. 3. Do not collect blood samples on an interim form. 4. Check name of referring Doctor with patient at every visit. Patient Details Doctor Details Laboratory Dose Doctor Dose (circle) Surname: Given Name: Surname lnitial DOB: Sex Telephone Address Address Post Code Telephone Fax: MEDICARE REPAT WORK COVER Copy Doctor Surname Initial Address Tests Requested Frequency Duration Change of Doctor / Practice Details Date: Clinical History Referral Date: R3X INR RECORD ONLY DATE DATE DATE Referral Date: R3X other than INR Record 6 visits in 6 months only or whichever comes first Test Dates: 1 Test Dates: 1 2 2 3 3 4 4. 5 5 6 6 Date lssued : 211A912010 Authorised by: Patient Centres Manager - Clayton vACC-R3EXRECRD-029 Page 1 of 2
