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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
| ☐ E11.9 Type 2 without complication | ☐ E1∅.9 Type 1 without complication |
|---|---|
| ☐ E11.65 Type 2 with hyperglycemia | ☐ E1∅.65 Type 1 with hyperglycemia |
| ☐ R73.∅9 PreDiabetes | ☐ Other: |
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
| Results | Date | |
| HbA1C | ____ | /____/____ |
| Total Cholesterol | ____ | /____/____ |
| LDL | ____ | /____/____ |
| HDL | ____ | /____/____ |
| Triglycerides | ____ | /____/____ |
| Urine | ____ | /____/____ |
| Microalbumin | ____ | /____/____ |
| OGTT results: | ||
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