Service provider information update
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.
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).
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)
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.
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.
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).
PART A: SERVICE DETAILS
Display name *
(name of service or practitioner)
Service Type *
Service description/ note *
(please provide a short paragraph that
describes the nature and purpose of the
service)
□ 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) ………………………………………………….
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.)
HPI-O/ HPI-FAC *
(please provide health provider ID number
if applicable)
Funding model *
□ Public
Service billing options:
Additional information- optional
□ No Fee
□ Fee
□ Bulk billing only
□ Fees and bulk billing
□ Co-payment
□ Other
(please tick all that apply)
□ Private
Criteria *
(e.g. patient is a NSW resident or presents
with a particular condition as listed in
service description)
Exclusions
Appointment required *
□ Yes
□ No
Priorities & urgent appointments * □ Yes
□ No
(are any particular patients or conditions
If yes, what are the conditions for priority?
given priority? Who? What is the process
for a referring practitioner or for a patient
requiring an urgent appointment? Include
details of drop-in clinics, teen clinics, etc.)
Online booking system available *
(e.g. existing patients can book via
Appointuit app)
If yes, what is the process?
□ Yes
□ No
If yes, briefly describe process:
Advice available by phone *
□ Yes
After Hours *
□ Yes
□ No
If Yes, briefly describe arrangements (how the service is provided
(Does your service have existing
arrangements for patients to access care in
the after hours’ period?)
and at what times):
□ No
Telehealth arrangements *
(video based consultation)
Our practice is equipped to offer telehealth 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):
Telehealth software utilised *
(if applicable)
Sub-region(s) covered by service *
(tick all that apply)
□ Skype
□ Lync
□ Consult Direct
□ Vidyo
□ WebEx
□ other (please specify)
……………………………………….
□ Cooma & Snowy Mountains
□ Bombala & Delegate
□ Eurobodalla
□ Far South Coast
□ Goulburn & Crookwell
□ Queanbeyan region & Yass
□ All Southern NSW
□ ACT
Internal notes
(e.g. wait list estimate)
Opening hours *
(please provide regular opening hours, with
an additional note for any irregularities e.g.
visiting specialist one Thursday per month
or service open one Sunday per month on
rotating roster with other local pharmacies,
etc.)
Accessibility elements and other
facilities available *
(tick all that apply)
Day
Open
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Other (please specify)
□ Translator/ interpreter service
□ Braille signage
□ Hearing induction loop
□ Accessible telephones
□ TTY facilities (hearing aid compatible)
Close
□ Accessible toilets
□ Public toilets
□ Parking- free
□ Parking- paid
□ Parking- suitable for seniors
□ Disability parking
□ Wheelchair accessible
□ Baby change facility
□ Parents’ room
□ Other (please specify) …………………………………………………….
PART B: SERVICE CONTACT DETAILS
Contact person *
Position held by contact person *
Street Address *
Postal Address *
Suburb/ Town *
Postcode *
State *
Phone *
Fax *
Email *
Website *
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)
Facility contact person
Position held by contact person
Street address
Postal address
Suburb / Town
Postcode
State
Phone
Fax
Email
Website
PART D: REFERRAL DETAILS
Accepts e-referrals *
□Yes
□ No
Accepts telephone referrals *
□Yes
□ No
If yes, referral phone number is ...……………………………………….
Acute referral phone number (if applicable) ……………………...
Accepts fax referrals *
□Yes
□ No
If yes, referral fax number is ………………………………………….....
Accepts email referrals *
□Yes
□ No
If yes, referral email address is ………………………………………….
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
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.
Name of contact person completing this form:
Position held:
Preferred contact method: □ Phone
Date:
□ Email
Please complete and return this form via email to: [email protected]