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 *

Month Day Year
Date
Gender *

Female Male
Address

Street Address

Street Address Line 2

City State / 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.

Cancel of
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 hrs Follow-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 Impairment Cognitive Impairment Hearing Impairment Language Limitations Physical Limitations Other
Diagnosis *

T1DM T2DM
ICD 10 Code *
Most Recent A1c *
Date of A1c *

Month Day Year
Date
DSME Content:

Monitoring Diabetes Diabetes as a disease process Psychological Adjustment Physical Activity Nutritional Management Goal Setting, Problem Solving Medications (Cost/Adherence) Managing Acute Complications Preventing Chronic Complications
Complications & Comorbidities

Hypertension Dyslipidemia Stroke Neuropathy PVD CHF CKD Retinopathy Obesity Non-healing wound Pregnancy Mental/affective d/o Other
Provider Name *
NPI *
Practice
Address
Phone *
Fax *
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

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