Diabetes Self-Management Education And Medical Nutritional Therapy Form printable pdf download

DIABETES SELF-MANAGEMENT EDUCATION AND MEDICAL NUTRITIONAL THERAPY

330 N. Clyde Morris Blvd., Suite 9, Daytona Beach, FL 32114 Phone (386) 226-4518

FAX orders (along with labs and progress notes) to: (386)238-3228

Name: _________________________________________________ FHCP # _________________________

Phone # _______________________ Cell Phone # ______________________ DOB: __________________

Diabetes Self-Management (DSMT):

(Medicare-10hrs initial DSMT in 12 month period, plus 2 hrs. follow-up annually)

□ Initial DSMT Group (10 hrs.) ___ # hrs. requested

Glucometer Training: □ Yes □ No

□ Follow-up DSMT (2 hrs.) _____ # hrs. requested

CGMS testing (clinic) □

□ Insulin Start Training: Type of Insulin: _____________ Amount of Insulin: ____________Time(s) __________

□ Patients with special needs requiring individual DSMT training (Check all that apply):

□ Vision □ Hearing □ Physical □ Language Limitations □ Other__________________

Diagnosis:

Diagnosis code:

□ Type 1 Controlled/Uncontrolled

_____________

□ Type 2 Controlled/Uncontrolled

_____________

□ Gestational

_____________

DSMT CONTENT Check education desired

All 10 content areas, as appropriate or:

□ Monitoring Diabetes

□ Diabetes disease process

□ Psychological adjustment

□ Physical activity

□ Nutritional management

□ Medications

□ Goal setting, problem solving

□ Prevent, detect and treat chronic complications

□ Prevent, detect and treat acute complications

□ Preconception/pregnancy or gestational management

Medical Nutrition Therapy (MNT): Medicare coverage: 3 hrs. initial MNT in the first calendar year, plus 2 hrs.

follow-up MNT annually. Additional MNT hours available for change in medical condition, treatment and/or

diagnosis. Check the type of MNT and/or number of additional hours requested:

□ Initial MNT □ 3 hrs or _____ # hrs requested

□ Annual follow-up MNT □ 2 hrs or _____ #hrs requested

□ Additional MNT services in the same calendar year, per RD recommendations _____ # additional hrs. requested

Please specify change in medical condition, treatment and/or diagnosis: __________________________________

Nutritional Counseling: □ Healthy Heart Eating (Lipid)

□ Increased Risk for Diabetes (Pre-diabetes)

□ Eat Right Move Right Adult Weight Management Program

□ Other (specify) _______________________

□ Diagnosis code _________

Lab Information: (Required)

Glucose: _____ A1C: ____ Cholesterol: ____ HDL: _____ LDL: _______

Triglycerides: ____

Weight: _____ Height: _____ BMI: ___

Medicare coverage of DSMT and MNT requires the physician to provide documentation of a diagnosis of diabetes

based on one of the following: □ FBS >126 mg/dl x 2 tests

□ Random > 200 mg/dl with symptoms

_____________________________________________

_______________

Physician Name and Provider Number

Date

17-105/1/09RX Rev. 11/14

Diabetes Self-Management Education And Medical Nutritional Therapy Form

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