Diabetes and Diabetes Prevention Referral Form

Diabetes Education

Referral Form
Panhandle Health District

8500 N. Atlas Rd

Hayden, ID 83835

Appointment Inquiry: (208)-415-5242

Fax: (208)-415-5141

Email: diabetes@phd1.idaho.gov
MEDICARE COVERAGE: Diabetes self-management education and support/training (DSMES/T) and medical nutrition therapy (MNT) are separate and complementary services to improve diabetes self-care. Individuals may be eligible for both services in the same year. Research indicates MNT combined with DSMES/T improves outcomes. DSMES and DSMT are the same thing: DSMT is the name of the Medicare Benefit.

DSMT: 10 hours initial DSMES in 12-month period from the date of first encounter, plus 2 hours follow-up per calendar year with signed referral from the treating qualified provider (MD/DO, APRN, NP or PA) each year.

MNT: 3 hrs initial MNT in the first calendar year, plus 2 hours follow-up MNT annually. Additional MNT hours with change in medical condition, treatment and/or diagnosis with signed referral from any physician (MD/DO).
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
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 DiabetesDiagnosis Code
Initial DSMES/T Or

Initial DSMES/T for 10 hours
Follow-Up DSMES/T

Follow-up DSMES/T for 2 hours
DSMES Content Areas:

All content areas identified by DSMES team on assessment OR specific content areas (check all that apply)Healthy copingHealthy eatingBeing activeTaking medication (including insulin and/or injection training)Reducing risk (treating acute and chronic complications)Problem solving (and behavior change strategies)MonitoringOther
If more than 1 hour individual initial training requested, please check special needs that apply:

VisionHearingLanguageCognitionPhysicalPsychosocialTransportationOther
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 208-415-5241.
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#
Practice Name:
Office Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Once the form is submitted, you will have the option of downloading the completed referral from the Thank You page. The form downloads as a PDF.
Should be Empty:

Diabetes Education

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 208-415-5241.