<PracticeLetterhead>
GP CHRONIC CONDITION MANAGEMENT PLAN
MBS Item 965/92029 or 392/92060	

Name:	
<PtFullName>	
	
Medicare No:	
<PtMCNo>	

Date of Birth:	
<PtDoB>	
	
Does Patient identify as Aboriginal or Torres
Strait Islander: <Does Patient identify as Aboriginal or Torres Strait Islander?>	

Phone:	
(M) <PtPhoneMob>	(H) <PtPhoneH>	

Address:	
<PtStreet>
<PtCity> <PtPostcode> <PtState>	

	

	
	
Usual Gp:	
<DrDetails>	

Details of Carer (if applicable):	

	

Name:	
<Carer Name:>	

	

Relationship to Patient:	
<Relationship to Patient:>	

	

Phone:	
<Carer Phone:>	

	

Date of last GPCCMP/Review (if done):	<Date of last GPCCMP/Review (if done):>	

Other notes or comments relevant to the patient’s management plan:
<Other notes or comments relevant to the patient’s management plan:>	

Medical/Surgical History:
<SelectedPMH>	

Medications:
<SelectedRx>	

Allergies:
<Reactions>	

Social History:
<SocialHx>	

Family History:
<FamilyHx>	

Current Progress Notes:
<TodaysVisit>	

   Chronic Condition Management Plan<CHRONIC CONDITION MANAGEMENT PLAN>	
Condition/Problem	<PtFirstName>'s SMART Goals	<PtFirstName>'s tasks, 
required treatments and services	Arrangements and referrals for treatments/services	
<First Condition: Problem>	<First Condition: SMART Goals>	<First Condition: Tasks, required treatments and services.>	<First condition: Arrangements and referrals for treatments/services.>	
<Second Condition: Problem>	<Second Condition: SMART Goals>	<Second Condition: Tasks, required treatments and services.>	<Second condition: Arrangements and referrals for treatments/services.>	
<Third Condition: Problem>	<Third Condition: SMART Goals>	<Third Condition: Tasks, required treatments and services.>	<Third condition: Arrangements and referrals for treatments/services.>	
<Fourth Condition: Problem>	<Fourth Condition: SMART Goals>	<Fourth Condition: Tasks, required treatments and services.>	<Fourth condition: Arrangements and referrals for treatments/services.>	

Date service was completed:	<TodaysDate>	Proposed Review Date:	<Proposed Review Date:>	

Copy of GPCCMP offered to patient?	<Copy of GPCCMP offered to patient?>	

GPCCMP added to the patient’s records?	<GPCCMP added to the patient’s records?>	

Copy of relevant parts of the GPCCMP supplied to other providers?	<Copy of relevant parts of the GPCCMP supplied to other providers?>	

I have explained the steps and any costs involved. The patient has agreed to proceed with the service.

GP’s Signature: _______________________________________________	Date: <TodaysDate>
GP Name: <DrName>	
<The patient consents to the preparation of this Management Plan and agrees to the outlined goals. Patient gives permission for the GP to share medical history/diagnosis with other service providers.> The patient consents to the preparation of this Management Plan and agrees to the outlined goals. Patient gives permission for the GP to share medical history/diagnosis with other service providers.
<Patient gives permission for the management plan to be uploaded to My Health Record.> Patient gives permission for the management plan to be uploaded to My Health Record.	

Any information the patient wants withheld:	
<Any information the patient wants withheld:>