Diabetes And Endocrine Order Form - Joslin Diabetes Center (Page 2 of 3) in pdf

To make a referral to Joslin please fax the following information to Joslin

Scheduling at (617) 264-2734.

____ Completed Orders/referral for Diabetes Therapy

____ Current Medications List

____ Last visit with past medical history OR relevant medical history

____ Relevant Lab results, including

____ Last A1c

____ Cholesterol

____ LDL

____ HDL

____ Triglycerides

____ Microalbumin

If clinical information is available on CareWeb fax just order the form.

For questions please call our provider referral line at (800) 497-7338.

What you can expect from Joslin:

JoslinCare provides an integrated approach to diabetes management. Patients receive sequenced diabetes

education including medical nutrition therapy and exercise.

Focusing on self-management: patients are provided with the tools and knowledge they need to achieve life

long health. All patients receive a summary of recommendations including a diabetes self-care action plan

and a free Joslin Vision Network Screening for eye disease.

Joslin will work closely with you to optimize your patient's care. You will receive:

A detailed consultation report to assist you in managing your patient.

A summary of recommendations, including a diabetes self-care action plan from a diabetes educator.

Assistance scheduling your patient appointments.

Confidentiality Notice

This fax transmission and any attachments may contain Protected Health Information (PHI). PHI is personal and sensitive

information related to a person’s health care. It is being faxed to you after appropriate authorization from the patient or under

circumstances that do not require patient authorization. You, the recipient, are obligated to maintain it in a safe, secure and

confidential manner. Re-disclosure without additional patient consent or as permitted by law is prohibited. Unauthorized re-

disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state law.

Important Warning: This message is intended for the use of the person or entity to which it is addressed and may contain

information that is privileged and confidential, the disclosure of which is governed by applicable law. If you are not the intended

recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that you have received

this communication in error and that any review, disclosure, copying or distribution of this information is strictly prohibited. If you

have received this message in error, please notify the sender immediately to arrange for return or destruction of these documents.

Rev. 9-29-0

Diabetes And Endocrine Order Form - Joslin Diabetes Center Page 2