Reporting Form for High Needs Skin Surgery and Palliative Care

HIGH NEED DISCRETIONARY FUND REPORTING FORM For Period 01 July 2018 – 31 December 2018

General Practice Name: _______________________________________________

Funds assigned for the Period

$

(GST excl.)

Funds remaining at 31 December

$

(GST excl.)

Number of Patients Assisted: How Were Patients Assisted:

Signed by: ___________________________

Date:____________________

SKIN SURGERY FUND REPORTING FORM For Period 01 July 2018 – 31 December 2018

General Practice Name: _______________________________________________

Funds assigned for the Period

$

(GST excl.)

Funds remaining at 31 December

$

(GST excl.)

Number of Patients Assisted: How Were Patients Assisted:

Signed by: ___________________________

Date:____________________

PALLIATIVE CARE REPORTING FORM For Period 01 July 2018 – 31 December 2018

General Practice Name: _______________________________________________

Funds assigned for the Period Funds remaining at 31 December

$

(GST excl.)

$

(GST excl.)

$

(GST excl.)

Number of Patients who have Received Subsidised Care Range of Utilisation per Patient Average Cost per Patient Average Utilisation per Patient Number of Patients who have Died at Home Percentage of Patients with a Care Plan

Signed by: ___________________________

Date:___________________