Referral Form for Diabetes Self-Management Education
Referral Form for Diabetes Self-Management Education
Diabetes Education 09/2018
Date of Referral: _________________________
Please Fax completed order to:
Diabetes Diagnosis: Indicate one or more reasons for referral:
Type 1 (ICD-10: E10) Newly diagnosed
Type 2 (ICD-10: E11) Recurrent elevated blood glucose levels
Other Specified DM (ICD-10: E13) Recurrent Hypoglycemia
Gestational (ICD-10: 024.41) Change in DM treatment regimen
Pre-Existing DM, T1 with Pregnancy (ICD-10: 024.01) High risk due to Diabetes Complications
Pre-Existing DM, T2 with Pregnancy (ICD-10: 024.11)
Pre-diabetes (ICD-R73.09)
Other ___________________________________ Education Needed:
Comprehensive Self-Management skills (group)
Height: __________ Date: __________ Comprehensive Self-Management skills (individual)
Weight: __________ Date: __________ Indicate any existing barriers requiring individual
Blood Pressure: __________ Date: __________ education (required for Medicare):
Impaired mobility
Recent Hgb A1C Lab: (required) Impaired vision
HgbA1C: __________ Date: __________ Impaired hearing
Impaired dexterity
Complications/Co-morbid conditions: Language barrier
Retinopathy Impaired mental status/cognition
Neuropathy Eating disorder
Nephropathy Learning disability (please specify): ______________
Gastroparesis Other (please specify): ________________________
Hyperlipidemia Insulin Instruction
Hypertension Medical Nutrition Therapy (MNT),
Cardiovascular disease physician signature required for Medicare patients
Other ___________________________________ Self-blood glucose monitoring
Management of Diabetes during Pregnancy/
Gestational Diabetes Education
This patient has clearance to exercise: Yes No
Diabetes Self-Management Program
Brunswick County Health Services
25 Courthouse Drive
Bolivia, NC 28422
910-253-2250 Fax: 910-253-2370
Patient Data:
Name: ____________________________
DOB: ____________________________
Phone #: ____________________________
Required: Please attach the following
**Demographic, labs, problem, & medication lists
I hereby certify that I am managing this beneficiary’s Diabetes condition and that the above prescribed training is
a necessary part of management.
Provider Signature (Required): ___________________________ Date: ____________________
Provider’s Name (Printed): ______________________________
NPI: ____________________________
Telephone: ______________________
For Office Use Only: Patient declined to schedule appointment
Patient did not keep appointment Left messages on the following dates to schedule:
Patient could not be reached to schedule apt. ____________________________________________
click to sign
click to edit