<Letterhead>

<TodaysDate>

Team Care Coordinator referral
Refer to: Team Care Coordination (MM4030000FT)

RE: <PtFullName>
DOB: <PtDoB>
Address: <PtAddress>
Phone: <PtPhoneH>

Medicare Number:<PtMCNo> <PtMCLine> <PtMCExpiry>
Pension Number: <PtPensionNo>

Reason for referral: <Reason for referral>

History List

<Reactions>
<FamilyHx>
<SelectedPMH>
<SelectedRx>
<SocialHx>

Kind Regards,

<DrName>
<DrProviderNo>