Reporting_Form_for_High_Needs_Skin_Surgery_and_Palliative_Care_Period_ (002)

HIGH NEED DISCRETIONARY FUND REPORTING FORM For Period 01 Jan 2020 – 30 June 2020

General Practice Name: _______________________________________________

Funds received for the Period

$

(GST excl.)

Funds utilised for the Period

$

(GST excl.)

Funds remaining at 30 June 2020

$

(GST excl.)

Number of Patients Assisted: How Were Patients Assisted:

Signed by: ___________________________

Date:____________________

SKIN SURGERY FUND REPORTING FORM For Period 01 Jan 2020 – 30 June 2020

General Practice Name: _______________________________________________

Funds received for the Period

$

(GST excl.)

Funds utilised for the Period

$

(GST excl.)

Funds remaining at 30 June 2020

$

(GST excl.)

Number of Patients Assisted: How Were Patients Assisted:

Signed by: ___________________________

Date:____________________

PALLIATIVE CARE REPORTING FORM For Period 01 Jan 2020 – 30 June 2020

General Practice Name: _______________________________________________

Funds received for the Period

$

(GST excl.)

Funds utilised for the Period

$

(GST excl.)

Funds remaining at 30 June 2020

$

(GST excl.)

$

(GST excl.)

Number of Patients who have Received Subsidised Care

Type of Services Funded for Patients

Average Cost per Patient Average number of Consults per patient Number of Patients who have Died at Home Percentage of Patients with a Care Plan

Signed by: ___________________________

Date:___________________