[ { "page": 1, "items": [ { "page": 1, "type": "TITLE", "location": { "l": 222, "t": 758.64, "r": 474.96, "b": 712.08 }, "text": "REFERRAL FORM\nDiabetes Self-Management Training\nurry County Health & Nutrition Center", "reading_order": 0, "level": 1 }, { "page": 1, "type": "FIGURE", "location": { "l": 491.76, "t": 751.68, "r": 570, "b": 714.72 }, "text": "", "reading_order": 1 }, { "page": 1, "type": "TITLE", "location": { "l": 14.16, "t": 733.2, "r": 192.24, "b": 719.76 }, "text": "PATIENT/ PHYSICIAN INFORMATION", "reading_order": 2, "level": 3 }, { "page": 1, "type": "TEXT", "location": { "l": 19.44, "t": 705.6, "r": 307.92, "b": 694.08 }, "text": "Patient's Name: ___ DOB: ___", "reading_order": 3 }, { "page": 1, "type": "TEXT", "location": { "l": 19.2, "t": 687.36, "r": 308.16, "b": 675.36 }, "text": "Address: ___", "reading_order": 4 }, { "page": 1, "type": "TEXT", "location": { "l": 319.44, "t": 704.88, "r": 583.92, "b": 692.88 }, "text": "
\"Image\"
\n\n\n
\"Image\"
\n\n\n", "reading_order": 5 }, { "page": 1, "type": "TEXT", "location": { "l": 319.44, "t": 686.88, "r": 582, "b": 674.4 }, "text": "Practice Name: ___", "reading_order": 6 }, { "page": 1, "type": "TEXT", "location": { "l": 19.2, "t": 668.4, "r": 306.48, "b": 656.4 }, "text": "Phone #: _____ SS#: _____\nPhysician Name: _____", "reading_order": 7 }, { "page": 1, "type": "TEXT", "location": { "l": 19.68, "t": 649.92, "r": 307.68, "b": 634.32 }, "text": "Insurance: ___\nFax #: ___", "reading_order": 8 }, { "page": 1, "type": "TEXT", "location": { "l": 320.16, "t": 668.64, "r": 584.16, "b": 656.16 }, "text": "Phone #:_____", "reading_order": 9 }, { "page": 1, "type": "TEXT", "location": { "l": 319.68, "t": 649.92, "r": 586.08, "b": 636 }, "text": "Fax #:", "reading_order": 10 }, { "page": 1, "type": "TEXT", "location": { "l": 16.08, "t": 626.4, "r": 583.68, "b": 606.72 }, "text": "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.", "reading_order": 11 }, { "page": 1, "type": "TITLE", "location": { "l": 18, "t": 602.88, "r": 264.72, "b": 590.64 }, "text": "DIABETES SELF-MANAGEMENT TRAINING (DSMT)", "reading_order": 12, "level": 3 }, { "page": 1, "type": "TITLE", "location": { "l": 310.32, "t": 602.64, "r": 497.52, "b": 590.16 }, "text": "MEDICAL NUTRITION THERAPY (MNT)", "reading_order": 13, "level": 3 }, { "page": 1, "type": "TITLE", "location": { "l": 21.12, "t": 588.24, "r": 300.96, "b": 568.32 }, "text": "Medicare: 10 hours initial DSMT in 12-month period, plus 2 hours follow-up DSMT annually", "reading_order": 14, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 22.56, "t": 567.6, "r": 281.52, "b": 556.56 }, "text": "*Check type of training services and number of hours requested:", "reading_order": 15 }, { "page": 1, "type": "TEXT", "location": { "l": 309.6, "t": 584.88, "r": 547.44, "b": 561.36 }, "text": "Medicare: 3 hours initial 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☐ 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:
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ResultsDate
HbA1C____/____/____
Total Cholesterol____/____/____
LDL____/____/____
HDL____/____/____
Triglycerides____/____/____
Urine____/____/____
Microalbumin____/____/____
OGTT results:
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