Fillable Referral Form for Diabetes Self-Management Education 910-253-2370 (Brunswick County)

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Referral Form for Diabetes Self-Management Education 910-253-2370 (Brunswick County)

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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:
910-253-2370
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. ____________________________________________
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Referral Form for Diabetes Self-Management Education 910-253-2370 (Brunswick County)

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Completed 1 April 2021

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