Diabetes Education Physician Order Form printable pdf download

DIABETES EDUCATION

PHYSICIAN ORDER FORM

PATIENT INFORMATION

Patient Name: ___________________________________________________________Date of Birth: _______________________

English-speaking

Non-English Speaking (language): __________________________________________________

Address: ___________________________________________________________________________________________________

Phone: (Primary) _________________________________________ (Secondary) ______________________________________

DIAGNOSIS

Type 2, newly diagnosed

Type 1, newly diagnosed

Gestational diabetes

Pre-diabetes

Type 2, uncontrolled

Type 1, uncontrolled

Pregestational diabetes

Other: _______________

MEDICAL NECESSITY

New Onset Diabetes Mellitus

Change in Treatment Plan

Inadequate Glycemic Control

DIABETES SELF-MANAGEMENT TRAINING (DSMT) and MEDICAL NUTRITION THERAPY (MNT)

Medicare covers 10 hours initial DSMT in 12-month period, plus 2 hours follow-up DSMT annually. Medicare MNT coverage includes

3 hours initial MNT in ﬁ rst calendar year, plus two hours follow-up MNT annually. Additional MNT hours available for change in

medical condition, treatment, and/or diagnosis.

Check education program and number of hours requested:

Initial DSMT - Comprehensive Program or

Follow-up DSMT - 2 hours

*approximate hours for education programs listed below or physician can specify ____ hours of DSMT

Type 2 {8-10 hours}, Type 1 {6-8 hours}, Gestational {4-10 hours}, Pre-gestational {4-10 hours}, Pre-Diabetes {4 hours}

Medication Instruction (insulin or other injectible)

Center to titrate per protocol

Physician to titrate medication

*Name of medication: ______________________________________________ Dose: ________________________________

Initial MNT - 3 hours or

Follow-Up MNT – 2 hours

Additional MNT services in the same calendar year, per dietitian recommendations ____ # additional hours requested

DSMT Content: All ten content areas, as appropriate, will be covered unless otherwise specified.

Monitoring diabetes

Diabetes as disease process

Medications

Psychological adjustment

Nutritional management

Physical activity

Goal setting, problem solving

Preconception/pregnancy

Prevent, detect and treat acute complications

Prevent, detect and treat chronic complications

Patient CAN NOT effectively participate in group instruction because of the following special needs:

Vision/Hearing

Language Limitations

Cognitive Impairment

Other: _____________________________

FAX completed form, COPY of insurance card, and labs (hemoglobin A1C, lipids, oral glucose tolerance

test) to location of your choice:

Baylor Ft. Worth (All Saints)

Baylor Ft. Worth (Southwest)

Baylor Grapevine

817-922-2192 (phone)

817-370-5988 (phone)

817-424-4542 (phone)

817-922-1951 (fax)

817-370-5981(fax)

817-424-4550 (fax)

Baylor Garland

Baylor Irving

Baylor Plano

972-487-5483 (phone)

972-579-4350 (phone)

469-814-6896 (phone)

972-485-3016 (fax)

972-579-4355 (fax)

469-814-6761 (fax)

Baylor Dallas (Ruth Collins & Ruth Collins at Mesquite)

Baylor Waxahachie

214-820-8988 (phone)

972-923-8047 (phone)

214-820-8985 (fax)

972-937-2063 (fax)

Physician Name (printed): _______________________________________ Phone #: ______________________ Fax #: ________________

Signature: ______________________________________________________ Referral Date: __________________ Time: _________________

(signature stamps are not acceptable)

BAYLOR HEALTH CARE SYSTEM

BHCS-49245 (08/10)

DIABETES EDUCATION

PHYSICIAN ORDER FORM

Diabetes Education Physician Order Form

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