Diabetes Self-Management Education Form
I am interested in learning more about managing my Diabetes
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Medicare Part B Information
Please insert your Medicare Part B information (Red, Whit, and Blue card)
Medicare Part B number
Medicare Part B start date
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Colorado Medicaid Information
Please insert the information from your CO medicaid card
CO medicaid number
Letter + six numbers
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Insurance Card Information
Please insert the information from your insurance card
BIN
PCN
ID number
Group number
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Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Female
Male
Race/Ethnicity
*
Caucasian/White
African American
Hispanic
Asian
American Indian
Pacific Islander
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
*
Email Address
example@example.com
Primary Care Provider (PCP) Name
*
First Name
Last Name
Primary Care Provider (PCP) Phone Number
*
Please enter a valid phone number.
Reason to sign up for DSME
Type 1 Diabetes
Type 2 Diabetes
Prediabetes
Gestational Diabetes
Please List Current Medications and/or Supplements You Are Taking
Which of the conditions below describe your health
*
Over 65
Cancer
Chronic Kidney Disease
COPD
Cardiovascular Disease
Heart Condition
Immunocompromised
Obesity
High Cholesterol
None
Other: _____________________________________
How often do you check your blood sugars?
*
What times of day do you usually check your blood sugars?
*
What goals do you have regarding your diabetes management?
What would you like to know more about diabetes?
Is there anyone who assists you with managing your diabetes?
When would be the best times for you to meet?
Consent to Initial Consultation
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*
First Name
Last Name
Representative name (if applicable)
First Name
Last Name
Signature
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