Diabetes self-management training (DSMT) and medical nutrition therapy (MNT) are DIABETES SELF-MANAGEMENT TRAINING (DSMT) Medicare: 10 hours initial DSMT …
Diabetes Services Order Form DSMT and MNT Services
Indicates required information for Medicare order PATIENT INFORMATION Patients Last Name Birth Date Address Home Phone
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First Name Medicare HICN City Work Phone State
Middle Male Gender Zip Code
Female
Other Contact Phone
Diabetes self-management training DSMT and medical nutrition therapy MNT are individual and complementary services to improve diabetes care For Medicare beneficiaries, both services can be ordered in the same year Research indicates MNT combined with DSMT improves outcomes
DIABETES SELF-MANAGEMENT TRAINING DSMT Medicare: 10 hours initial DSMT in 12 month period, plus 2 hours follow-up DSMT annually Check type of training services and number of hours requested: Initial group DSMT: Follow-up DSMT: 10 hours or 2 hours or no hrs requested no hrs requested no hrs requested
MEDICAL NUTRITION THERAPY MNT Medicare: 3 hours initial MNT in the first calendar year, plus two hours 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 Annual follow-up MNT Additional MNT services
in the same calendar year, per RD recommendations no additional hrs requested Please specify change in medical condition, treatment and/or diagnosis:
Additional insulin training:
Patients with special needs requiring individual DSMT Check all special needs that apply: Vision Hearing Physical Cognitive Impairment Language limitations Other
DSMT Content All ten content areas, as appropriate Monitoring diabetes Diabetes as disease process Psychological adjustment Physical activity Nutritional management Goal setting, problem solving Medications Prevent, detect and treat acute complications Preconception/pregnancy management or gestational Prevent, detect and treat diabetes management chronic complications DIAGNOSIS Please send recent labs for patient eligibility outcomes monitoring Type 1 uncontrolled Type 2 uncontrolled Gestational diabetes Type 1 controlled Type 2 controlled Other
CURRENT DIABETES MEDICATIONS Specify type, dose and frequency Oral:
Insulin:
Patient now uses:
Pen
Needle
Pump
PATIENT BEHAVIOR GOALS/PLAN OF CARE
Complications/Comorbidities Check all that apply: Hypertension Dyslipidemia Neuropathy Nephropathy Renal disease Retinopathy Non-healing wound
Pregnancy Mental/affective disorder Other
Stroke PVD CHD Obesity
Signature and UPIN Group/practice name, address and phone:
Date
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Revised 8/31/05 by the American Dietetic Association and the American Association of Diabetes Educators after substantial review and consultation Authors do not recommend or endorse any revisions or modifications
Source:diabetesnm.org
