Diabetes Self Management Program Referral Form
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1Phone: (603) 650-8630
Fax: (603) 650-2240
Referral Form
Diabetes Self Management Program
Patient Name: ______________________________________________________________ Today’s Date: _____________________
DOB: _______________________________________________________ SSN: ____________________________________________
Mailing Address: ________________________________________________________________________________________________
Home Phone: ________________________ Work Phone: _________________________ Cell Phone: ________________________
Health Insurance: ____________________________________________________________ Policy #: __________________________
Referring Provider: __________________________________________________________ Office #: __________________________
Practice Name: ______________________________________________________________ Fax #: ____________________________
Diabetes Diagnosis:
Type 1, controlled
Type 2, controlled
Gestational
Pre-existing DM with pregnancy
Type 1, uncontrolled
Type 2, uncontrolled
Pre-diabetes
Current Treatment:
Diet & exercise
Oral agents: _________________________
Insulin: _________________________
Indicate one or more reasons for referral:
Recurrent elevated blood glucose levels
Recurrent Hypoglycemia
Change in DM treatment regiment
High risk due to Diabetes complications/co-morbid conditions (check all that apply):
Retinopathy
Neuropathy
Nephropathy
Cardiovascular Disease
Hypertension
Gastroparesis
Hyperlipidemia
Other: _________________________________
Recent Labs:
FBG: ______________________ Date: _____________
HgbA1C: _____________ Date: _____________
Micro-albumin: _____________ Date: _____________
HDL: _________________ Date: _____________
Total Cholesterol: ___________ Date: _____________
LDL: __________________ Date: _____________
Triglycerides: _______________ Date: _____________
Education needed:
Comprehensive self management skills (group)
Insulin instruction
Comprehensive self management skills (individual sessions)
Insulin pump instruction
Medical Nutrition Therapy (MNT)
Basic nutrition management
Management of Diabetes during pregnancy/
Self blood glucose monitoring
Gestational Diabetes Education
Indicate any existing barriers requiring customized education:
Impaired mobility
Impaired vision
Impaired hearing
Impaired mental status/cognition
Impaired dexterity
Language barrier
Eating disorder
Learning disability (please specify): ______________________________________________________________________
Other (please specify): _________________________________________________________________________________
I hereby certify that I am managing this beneficiary’s Diabetes condition and that the above prescribed training is a
necessary part of management. (Medicare patients)
Physician’s signature (required): ______________________________________________________________________________
One Medical Center Drive | Lebanon, NH 03756 | Tel: (603) 650-5000 |
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