DSMES A1c Release Form

Maggy Pharmacy has a referral program for patients with diabetes who are struggling to reduce their A1c. If you have an A1c between 7 and 9 or above, we can refer you for DSMES (Diabetes Self-Management Education and Support). Very often patients with Diabetes need help to control their blood sugars. Controlling your A1c is the key to reducing future complications from diabetes such as eye problems, neuropathy, microvascular and macrovascular issues which can cause heart attack, stroke, problems with your kidneys and feet.

We believe this is a great options for patients struggling with their diabetes and we want to be part of the team that helps educate you, to improve your health. Allowing us to know your A1c is all it takes. Take the first step today and learn more about Diabetes and how it can be better controlled. By filling out the form below, we can fax this to your Doctors office to find out your A1c. If you had a recent A1c and you know what it is, we can use this value to do the referral.

Referral to the DSMES center is not guaranteed, and any costs associated or copays with referral center are at your discretion to proceed.

Today's Date *

Date

Patient Name: *

First Name Last Name

Date of Birth *

Date

If you had a recent A1c lab value please enter it here:

A1c lab: example 7.3

Date of Last lab with A1c:

A1c lab: example 8.5

Name of your Doctor: *

Phone Number of your Doctor:

I hereby give representatives of Maggy Pharmacy Inc permission to secure and obtain my medical history and lab data regarding my diabetes from my provider as it relates to my participation in a DSMES (Diabets Self-Management Education and Support). Necessary lab values and data include the most recent:

* Hemoglobin A1c (HbA1c)

Please enter values here and Fax back to us at 518-492-7311

HbA1c Value (%) ____________ Date of HbA1c _____________

* If NO current A1c is on file please check here __________

At this time, please release any lab values and data regarding my diabetes to Maggy Pharmacy Inc. Please send to the fax number listed above.

Thank you,

Signature *

Clear

A1c Patient Consent and Release Form