Phone: 315-462-0220
Fax: 315-462-3767
DIABETES SELF-MANAGEMENT EDUCATION/TRAINING ORDER FORM
Phone Number ________________________________
Alternate phone # ______________________________
Home address __________________________
____________________________________
____________________________________
I am referring: ________________________________________ for
medically necessary outpatient diabetes self-management training.
Insurance/Health Plan______________________________________
Date of Birth:____________________
DIAGNOSIS
ICD-9 CODE:
 250.00 Diabetes type 2 controlled
 250.02 Diabetes type 2 uncontrolled
 Other _______________________
 250.01 Diabetes type 1 controlled
 250.03 Diabetes type 1 uncontrolled
MEDICAL STATUS
AND / OR
COMPLICATIONS:
 Newly diagnosed
 New to insulin
 New to oral anti-diabetes agents
DESIRED PLASMA
 Unless otherwise prescribed, target glucose values to be: (for non-preg adult)
Pre-prandial: 70-130 mg/dl & Post-prandial: less than 180 mg/dl
GLUCOSE RANGE
RECENT RESULTS: (or may fax
lab result slips with this form)
 Severe hypo/hyperglycemia
 Retinopathy
 Neuropathy
A1C ___________
Cholesterol ________
Date ___________
DANGEROUS ABBREVIATIONS: Nitro drip, µg, QD, qd,
QN, qn, Qh, qh, Q6pm, QOD, qod, Sc, sc, U, u, IU, MS,
MSO4, MgSO4, x3d, lack of leading zero, trailing zeros
 790.29 Abnormal GT (pre-diabetes)
 277.7 Dysmetabolic syndrome
 256.4 Polycystic ovarian syndrome
 Vascular Disease
 Nephropathy
 Gastroparesis
LDL _______
 Hyperlipidemia
 Obesity
 Other: _______________
 Pre-prandial:
mg/dl
 Post-prandial: less than _________ mg/dl
HDL ________
Trig ________
Date _________________
PLAN OF CARE: Please check appropriate sections
 In case of hypoglycemia, follow
outpatient hypoglycemia protocol.
 Diabetes Self-Management Education/Training (DSME/T)
 Patients with special needs requiring individual DSME/T
Check all special needs that apply:
 Vision  Hearing  Physical  Cognitive Impairment  Language Limitations
 Additional training needed  Additional hours requested _______  Other______________________
 Insulin Initiation
Insulin type(s), dose(s), time: ____________________________________________________________
Continue oral medications?  Yes  No / Oral med dose change?  Yes  No ____________________
Specific content areas Educator to focus on: (if not checked, Educator to determine based on assessment)
 Nutritional management
 Monitoring diabetes
 Medications
 Physical activity
 Diabetes as a disease process  Psychological adjustment  Prevent, detect and treat acute complications
 Prevent, detect and treat chronic complications
 Preconception/pregnancy management of GDM/Diabetes with pregnancy
Hours of education: (if not checked, Educator to determine hours based on patient assessment)
 Up to 10 hours  ______ number of hours requested
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 Continuous Glucose Monitor
 Unless otherwise ordered, sensor will be unblinded.  Blinded
 Pre-pump / insulin pump instruction 1 to 6.5 hours
Basal rate(s) __________________________________________________ BG Target Range ______________
ICR (Insulin to Carb Ratio) _____________________ ISF (Insulin Sensitivity Factor) ____________________
 Certified Diabetes Educator to determine ICR and ISF
Provider Signature:
Date/Time:
Print Name:
Phone:
Please fax completed form to 315-462-3767 or mail to CSHC Regional Diabetes Health Center.
106747567