REFERRAL FORM Diabetes Self-Management Training urry County Health & Nutrition Center

PATIENT/ PHYSICIAN INFORMATION

Patient's Name: ___ DOB: ___

Address: ___

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Practice Name: ___

Phone #: _____ SS#: _____ Physician Name: _____

Insurance: ___ Fax #: ___

Phone #:_____

Fax #:

Diabetes self-management training (DSMT) and medical nutrition therapy (MNT) are individual and complementary services to improve diabetes care. For Medicare beneficiaries, both services can be ordered in the same year. Research indicates MNT combined with DSMT improves outcomes.

DIABETES SELF-MANAGEMENT TRAINING (DSMT)

MEDICAL NUTRITION THERAPY (MNT)

Medicare: 10 hours initial DSMT in 12-month period, plus 2 hours follow-up DSMT annually

*Check type of training services and number of hours requested:

Medicare: 3 hours initial MNT in the first calendar year, plus two hours follow-up MNT annually.

• * Check the type of MNT:

Initial Ind./Group DSMT (10 hours) or

□ Follow-up DSMT (2 hours) or

___no. hrs. requested ___no. hrs. requested ___no. hrs. requested

□ Additional insulin training (1 hour) or

Initial Individual MNT Annual follow-up MNT*MD Signature required for MNT order

CURRENT DIABETES MEDICATIONS

* Patients with special needs requiring only individual DSMT Check all special needs that apply:

□ Vision □ Hearing □ Physical □ Cognitive Impairment □ Language □ Low Literacy □ Psychosocial Impairment Other ___

Other ___

DSMT Content:

ALL TEN CONTENT AREAS, as appropriate

□ Diabetes as disease process □ Monitoring

□ Nutritional management

Medications

Preconception/pregnancy management or gestational diabetes management Psychological adjustment

Psychological adjustment

Physical activity

Goal setting, problem solving Prevent, detect and treat acute complications

acute complications

Prevent, detect and treat chronic complications

DIAGNOSIS

Fasting___ 1H___ 2H___ 3H___ Date___/___/___

Complications/Comorbidities

Check all that apply:

☐ Hypertension Chronic Renal Insufficiency

☐ Dyslipidemia

☐ Coronary Artery Disease ☐ Retinopathy

□ Non-healing wound □ Stroke

Oral:

Insulin: (New Initiation of Insulin? ___Yes ___No)

Other Pertinent Meds:___

[Unlabeled]

Exercise restrictions? ___ No ___ Yes: ___

LABS

Age ___ Height ___ Weight ___ BMI ___

Any Other Special Instructions/Behavioral Goals or Plans

☐ Neuropathy

Obesity

☐ PVD

-Frequency of Blood Glucose Testing: ___

-Other: ___

Mental/affective disorder Chronic Renal Insufficiency

Pregnancy

□Other___

*REQUIRED-Physician Signature:___ NPI#:___ Date:___/___/___

Other Provider Rendering Care:___ NPI#___ Date://___/___

Please FAX or MAIL this completed referral form to the Surry County Health & Nutrition Center 118 Hamby Road, Dobson, NC 27017; FAX (336) 401-8408; Phone (336) 401-8419