REFERRAL FORM DSME 5.13.13

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REFERRAL FORM
Medical Nutrition Therapy
Diabetes Self Management Education

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REFERRAL FORM DSME 5.13.13

  1. 1. REFERRAL FORMMedical Nutrition TherapyDiabetes Self Management Education4986 Adams Rd., Suite E, Rochester, MI 48306Tel: 866.648.3265 ▪ 248.475.4880 ▪ Fax: 248.475.5777 ▪ www.mednetone.net© 2008 Michigan Institute for Health EnhancementPhone number: 866-648-3265 or 248-475-4880 Fax number: 248-475-5777***Please provide patient with a copy and fax a copy to (248) 475-5777PATIENT INFORMATIONDate: Patient’s Name: DOB: Age:Phone # (H): Phone # (W): Phone# (C):Address: Email:Health Insurance: Contract ID Number:NEED FOR SELF-MANAGEMENT EDUCATION Medical Nutrition Therapy: Please describe reason for patient referral:________________________________________________Medicare: 3 hours initial MNT in the first calendar year, plus two hours follow-up MNT annually. Additional MNT hoursare available for change in medical condition, treatment and/or diagnosis. Please check the type of MNT and/or number ofadditional hours requested. Initial MNT Annual follow-up MNT Additional Services in the same calendar year, per RD recommendation ______ hours requestedBlood Pressure: ___________/___________ Height: ___________ Weight: __________Diabetes Self Management Training (9-11 hours) is medically necessary for the following reasons: Recent Diagnosis (please include diagnostic lab work)  Poorly controlled diabetes  Lack of current self-care knowledge/skillsDiagnosis: (Check all that apply) Diabetes Type 1 250.01  Morbid Obesity 278.01 Diabetes Type 2 250.02  Obesity 278.00 Heart Disease 429.9  Pre-diabetes 790.29 Hyperlipidemia 272.4  Post-surgical malabsorption 579.3 Hypertension 401.9  Renal Disease 593.9 Hypoglycemia 251.2  Other:____________________**Please attach lab work: FBS  Cholesterol Triglycerides RBS  HDL Micro albumin HgbA1C  LDL Other: _____________________List Medications:Medication Dosage FrequencyREFERRING PHYSICIAN INFORMATIONPhysician/Clinician Signature: Phone:Physician/Clinician Name (Print): Fax:Physician Address: Email:1137-01.06032008

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