• Diabetes and Diabetes Prevention

    Referral Form
    Diabetes and Diabetes Prevention
  • 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:

  • *Other payors may have other coverage requirements. (Sorce: Volume 68, #216, November 7, 2003, pg 63261/Federal Register)

  • Patient Information

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  • 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.

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