Diabetes and Diabetes Prevention Referral Form

Diabetes and Diabetes Prevention

Referral Form
Panhandle Health District

8500 N. Atlas Rd

Hayden, ID 83835

Appointment Line: (208)-415-5270

Fax: (208)-415-5101
Diabetes self-management training (DSMT) and medical nutrition therapy (MNT) are individual and complementary services to improve diabetes care. Both services can be ordered in the same year. Research indicates MNT combined with DSMT improves outcomes. MNT is specific for diabetes education. Diabetes Prevention Program (DPP) can reduce the risk for developing type 2 diabetes by 58% and establish healthy lifestyle changes in individuals.
DSMES/T: 10 hours initial DSMES/T in 12-month period from the date of first session, plus 2 hours follow-up per calendar year with written referral from the treating qualified provider (MD/DO, APRN, NP or PA) each year.

MNT: 3 hours initial MNT in the ﬁrst calendar year, plus 2 hours follow-up MNT annually. Additional MNT hours available for change in medical condition, treatment and/or diagnosis with a written referral from any physician (MD/DO).

DPP: A one-year program created by the Centers for Disease Control and Prevention to assist in healthy lifestyle change.

*Medicare coverage requires referring provider to maintain documentation of a diagnosis of diabetes based on the following:
Please choose:*

Diabetes: Fasting blood glucose greater than or equal to 126 mg/dl on 2 different occasionsDiabetes: 2 hour post- glucose challenge greater or equal to 200 mg/dl on 2 different occasionsDiabetes: random glucose test over 200 mg/dl with symptoms of uncontrolled diabetesPrediabetes: Hemoglobin A1c level 5.7%-6.4% or fasting blood glucose in between 100 and 125 mg/dl
*Other payors may have other coverage requirements. (Sorce: Volume 68, #216, November 7, 2003, pg 63261/Federal Register)
Patient Information
Name

First NameMiddle NameLast Name
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Diagnosis:*

Type 1Type 2Gestational DiabetesPre-diabetesDiagnosis Code
Initial DSMES/T Or

Initial DSMES/T for 10 hoursInitial DSMES/T for __ Hours
Follow-Up DSMES/T

Follow-up DSMES/T for 2 hours
If more than 1 hour individual initial training requested, please check special needs that apply:

VisionHearingLanguageCognitionPhysicalNo group sessions available within 2 monthsPandemicOther
All content areas identified by DSMES team on assessment OR specific content areas (check all that apply)Pathophysiology of diabetes and treatment optionsHealthy copingHealthy eatingBeing activeTaking medication (including insulin and/or injection training)Reducing risk (treating acute and chronic complications)Problem solving (and behavior change strategies)Preconception, pregnancy, gestational diabetesMonitoring
Medical Nutrition Therapy (MNT)

Initial MNT 3 HoursAnnual follow-up MNT 2 hoursAdditional MNT hours for change in:Medical conditionTreatmentDiagnosis
Please fax chart notes from most recent visit, current list of medications, and upload or fax most recent lab work (within the last 12 months) to 208-415-5131.
The information requested is Protected Health Information (PHI) and is the minimum necessary to execute delivery of patient services. Please understand that as a link in the "Chain of Trust", all PHI will remain confidential as mandated by the Treatment, Payments, and Healthcare Operation Laws mandated by HIPPA.
Signature of qualifies provider certifies that he or she is managing the beneficiary's diabetes care for DSMT referrals.*

Clear
Provider Name*
Date

MonthDayYear
Date
NPI#
Group Practice Name:
Office Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Should be Empty:

Diabetes and Diabetes Prevention

Patient Information

Please fax chart notes from most recent visit, current list of medications, and upload or fax most recent lab work (within the last 12 months) to 208-415-5131.