Diabetes Self-Management Education Referral Form

Diabetes Self-Management Education Referral Form
West Towne Pharmacy

1619 West Market St

Johnson City, TN37604

P (423)926-9137

F (423)926-7321
Patient Name*
DOB*

MonthDayYear
Date
Gender*

FemaleMale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Social Security #
Insurance Plan
Please upload a copy of the patient's insurance cards below or fax to 423-926-7321.

Cancelof
Diabetes self-management education (DSME) is used to enhance patients' knowledge about diabetes. We seek to target barriers of optimal self-care and work with patients to overcome these barriers and empower them to make healthier decisions at home. As a part of the program, we will maintain communication via fax or phone of patient progress, goal-setting, etc. Most insurance companies cover 10 hours of initial DSME for patients with diagnosed diabetes mellitus and 2 hours of annual follow-up.
DSME Type Requested:*

Initial Group DSME 10 hrs (Standard enrollment)Initial 1-on-1 DSME 10 hrsFollow-up Group DSME 2 hrs (Standard continuation)Follow-up 1-on-1 DSME 2 hrs
Patient must meet one of the following to qualify for 1-on-1 education. Please select the appropriate response(s):*

Visual ImpairmentCognitive ImpairmentHearing ImpairmentLanguage LimitationsPhysical LimitationsOther
Diagnosis*

T1DMT2DM
ICD 10 Code*
Most Recent A1c*
Date of A1c*

MonthDayYear
Date
DSME Content:

Monitoring DiabetesDiabetes as a disease processPsychological AdjustmentPhysical ActivityNutritional ManagementGoal Setting, Problem SolvingMedications (Cost/Adherence)Managing Acute ComplicationsPreventing Chronic Complications
Complications & Comorbidities*

HypertensionDyslipidemiaStrokeNeuropathyPVDCHFCKDRetinopathyObesityNon-healing woundPregnancyMental/affective d/oOther
Provider Name*
NPI*
Practice*
Address*
Phone*
Fax*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: