===== PAGE 1 ===== ## PATIENT/ PHYSICIAN INFORMATION # REFERRAL FORM Diabetes Self-Management Training urry County Health & Nutrition Center
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Patient's Name: ___ DOB: ___ Address: ___ Phone #: _____ SS#: _____ Physician Name: _____ Practice Name: ___ Phone #:_____ Insurance: ___ 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) ## 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: 「 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 ##* 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:
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## ALL TEN CONTENT AREAS, as appropriate □ Diabetes as disease process □ Monitoring □ Nutritional management Medications Preconception/pregnancy management or gestational diabetes management 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:
## Complications/Comorbidities Check all that apply: ☐ Hypertension ☐ Dyslipidemia Coronary Artery Disease Non-healing wound Mental/affective disorder Chronic Renal Insufficiency ☐ Neuropathy Retinopathy □ Stroke Pregnancy Obesity ☐ PVD □Other___ ## MEDICAL NUTRITION THERAPY (MNT) Medicare: 3 hours initial MNT in the first calendar year, plus two hours follow-up MNT annually.* Check the type of MNT: Fasting___ 1H___ 2H___ 3H___ Date___/___/___ Initial Individual MNT Annual follow-up MNT*MD Signature required for MNT order ## CURRENT DIABETES MEDICATIONS
Oral:
Insulin: (New Initiation of Insulin? ___Yes ___No)
Other Pertinent Meds:___ ## [Unlabeled] Exercise restrictions? ___ No ___ Yes: ___ ## LABS
ResultsDate
HbA1C____/____/____
Total Cholesterol____/____/____
LDL____/____/____
HDL____/____/____
Triglycerides____/____/____
Urine____/____/____
Microalbumin____/____/____
OGTT results:
Age ___ Height ___ Weight ___ BMI ___ ## Any Other Special Instructions/Behavioral Goals or Plans -Frequency of Blood Glucose Testing: ___ -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