DIABETES SELF-MANAGEMENT EDUCATION (DSME)

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DIABETES SELF-MANAGEMENT EDUCATION (DSME)

  1. 1. Choose location: 4986 Adams Rd. ▪ Rochester 2865 West Rd ▪ Trenton 30061 Schoenherr Rd ▪ Warren DIABETES SELF-MANAGEMENT EDUCATION (DSME) MEDICAL NUTRITIONAL THERAPY (MNT) REQUEST FORM Phone number: 866-648-3265 or 248-475-4880 Fax number: 248-475-4881 E-mail: info@miteam.org PATIENT INFORMATIONPatient’s last name: First: Middle:Gender: DOB: Health Plan: ID #: Male  Female / /Street address: Home phone number: Work/Cell number: ( ) ( )City: State: ZIP Code:DIAGNOSIS DIABETES SELF-MANAGEMENT EDUCATION(Please send recent labs for outcomes evaluation) (Check types of education being ordered)  Initial training Diabetes Type 1 controlled  Diabetes Type 1 uncontrolled Diabetes Type 2 controlled  Diabetes Type 2 uncontrolled Patient has special need(s) to receive individual instruction (Check all that apply) Gestational Diabetes  Vision  Hearing  Physical  Cognitive Impairment Other:  Language Limitations  Other:  Follow-up trainingDiabetes Self-Management Education (DSME) and Medical Nutrition Therapy (MNT) are services to improve diabetes care.COMPLICATIONS/COMORBIDITIES: MEDICAL NUTRITION THERAPY:(CHECK ALL THAT APPLY) Provided by the Registered Dietitian (RD) Hypoglycemia  Pre-diabetes  Stroke  Initial MNT Hyperlipidemia  Renal Disease  CAD  Annual Follow- up MNT Hypertension  Retinopathy  CHF  Additional MNT services in the same calendar year, per RD Non Healing Wound  Neuropathy  COPD recommendations Chronic Depression  Asthma  Obesity Please specify any changes in diagnosis, medical condition or Chronic Pain treatment regimens: Other:LIST MEDICATIONS: RESULT:(Specify type, dose, frequency)  A1C ___________  Foot Exam ____________  B/P ____________  Ret. Eye Exam _________  LDL ___________  HDL ___________  CHOL __________  TG _____________SIGNATURE & NPI: DATE:PRACTICE NAME:ADDRESS: PHONE: ( ) - 1290-01.03252009

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