This document contains a request form for diabetes self-management education (DSME) and medical nutritional therapy (MNT). It requests patient information like name, DOB, address, diagnosis, and medications. It also requests the type of DSME being ordered like initial training, follow up training, or special needs. For MNT, it requests initial sessions, annual follow ups, or additional services. Clinical information is also requested like complications, comorbidities, and recent lab results. The form is to be signed and dated by the referring provider and includes contact information.

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 INFORMATION
Patient’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 training
Diabetes 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