BWCPM Referral Guidelines
The Barbara Walker Centre for Pain Management is a Medicare Bulk Billing Clinic. To ensure your referral meets Medicare referral requirements for Bulk Billing, please use the accompanying referral template or write your referral is to:
The referral must include a Doctors name:

Dr Jane Trinca - Medical Director

Dr Aston Wan – Pain Consultant / Special interest in migraines

Dr Safa Hamza – Interventionist / Rehab Consultant / Pain Consultant

Dr Harry Eeman – Rehab Consultant / Pain Consultant

Dr Charles Kim – Pain Consultant

Dr Antje Ham – Dental Pain Consultant
At: The Barbara Walker Centre for Pain Management
To ensure that your patient is appropriately triaged and waitlisted please provide the following
mandatory clinical information

Referrer name and provider number

Patient name, address and contact number(s)

Preferred language / need for interpreter

Detailed reason for referral

Duration of referral ( 3months / 12months / indefinite)

Past medical history, including relevant psychosocial factors

Management to date, and response to treatment

Current medications, allergies - and medication history if relevant

Relevant imaging and pathology reports
If you believe your patient should be seen urgently, or fast tracked, please state the reason.
S8 permits: While your patient is on our waiting list, a referral acknowledgement letter can be used to liaise with DPU to request a 3month interim permit. Please indicate in your referral if an acknowledgement letter is required for this purpose.
Telehealth: Please note that BWCPM is able to provide telehealth consultation for those patients for whom travel is difficult, or to provide GP support. Please indicate if you feel this type of consult is helpful for your patient, and include details of your telehealth capacity.
Regional patients: Should your patient be required to travel more than 100km one way, in order to attend our clinic, they may be eligible for financial assistance through the Victorian Patient Transport
Assistance Scheme (VPTAS). Please refer your patient to VPTAS if this support is required. Brochures about VPTAS are available through the clinic.
Clinic DNA (Did Not Attend) Process: The BWCPM is a state wide service. In order to ensure equitable access, and reduce waiting time, please be aware that we require 24hrs notice of inability to attend an appointment. Failure to provide this notice results in a DNA. Should a patient have 2
DNA’s, BWCPM reserves the right to discharge the patient depending on individual assessment of
circumstances. Re-entry into the clinic will then require a new referral.

To: Dr …………………………… Referrer Stamp
Barbara Walker Centre for Pain Management
Level 1, Daly Wing
35 Victoria Parade
Fitzroy, Vic. 3065
PH: (03) 9288 4681
Referrer Stamp
Fax: (03) 9288 4660
Dear Dr………………………………..
RE: Patient Name:
Address:
Phone (H) (Mob)
D.O.B: / /
St Vincents UR (if known)
Interpreter Required ☐ No ☐ Yes Preferred Language:…………………………………..
I am referring the above patient to the Barbara Walker Centre for Pain Management for specialist pain assessment, opinion and management.
 Current pain management issues / response to treatment:
Urgency: ☐ 1 month ☐ 6 months ☐ Longer

Past Medical History:
☐ HT ☐ IDDM ☐ NIDDM ☐ CCF ☐ CABG ☐ CVA ☐ MVA ☐ Depression / Anxiety ☐ PTSD

Workcover ☐ TAC ☐ Claim Number:
 Any attached imaging / results ☐ Yes ☐ No

Allergies:

Medications:
Referral valid for
☐ 3months (specialist referral)
☐ 12 months (GP referral)
☐ Indefinite (related to a chronic / ongoing pain issue)
☐ Referral Acknowledgement letter required for S8 interim permit application
☐ Telehealth Consult preferred. Preferred Telehealth Platform:
Referrer Name: Provider Number:
Signed: date: / /
PH:
Please complete all fields and fax to Barbara Walker Centre for Pain Management Fax: 03 9288 4660
Thank-you.