Preexisting Diabetes with Pregnancy I certify that diabetes self-management/medical nutrition therapy education is Oklahoma Diabetes Center at the OU …
Oklahoma Diabetes Center
Diabetes Self - Management/Medical Nutrition Therapy
Certificate of Medical Necessity FAX REFERRAL
TO: 405 271-7522
REFERRAL QUESTIONS: 405 271-
3455
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|Patients Name _____________________________________________________ Male____ |
|Female____ DOB _________________ |
| |
|Address ________________________________________________________ |
|City__________________________ Zip ____________ |
| |
|Social Security ____________________________________ Phone H_______________________|
|W_______________________ |
|Please include a patient information sheet |
|Payor |
|
|Information |Carrier__________________________ Authorization ___________________ |
|Diagnosis | ____ Type 2/No Insulin ____ Type 2/Insulin ____ Type 1 |
|check one |____ Gestational |
| |____ Preexisting Diabetes with Pregnancy |
| |____ Impaired Glucose Tolerance ____ Impaired Fasting Glucose |
| |____ Renal Failure |
|Medical | |
|Condition |____ New onset diabetes |
|check one or |____ Inadequate glycemic control HbAlc 80 x2Medicare |
|more |____ Change in treatment |
| |____ High risk for complications - change in clinical status as |
| |manifested by new symptoms |
| |____ Diabetes and Nephropathy |
|
|____ Diabetes and Cardiovascular Disease |
| | |
|Special Needs |Impairment of : vision__________hearing______language_________other |
|Requires 1:1 |__________ |
| | |
| | |
|Required |H P Please include current medications |
|Information |Medicare requires: HbA1c _________ Date _____/_____/_____ |
| |TCHOL _________ Date _____/_____/_____ |
| |TG _________ HDL _________ LDL _________ |
| |BUN _________ Creat _________ Microalbuminuria _________ |
| |_____Diabetes Self-Management Training/DSMT group class - content |
|Training |includes diabetes disease process, nutrition management, medications, |
|requested: |monitoring , physical activity, acute and chronic
complications, goal |
| |setting and problem solving, psychosocial and pregnancy |
| |_____Intensive Management pick one group class - requires existing |
| |knowledge of diabetes or renal failure This class is intended for |
| |persons that require more intensive management of their diabetes or |
| |renal failure |
| |_____ Renal Failure/Disease _____ Diabetes and |
| |Cardiovascular Disease |
| |_____ Intensive Insulin Management _____ Pre-pump |
| |_____ Renal Disease Instruction Group - content includes renal |
| |disease process, nutrition management, medication, acute and chronic |
| |complications, goal setting and problem solving, psychosocial |
| |_____Individual Instruction - please identify specific request |
| |_____________________________________ |
| |Medicare
requires: Check type of training |
|Other |___Initial group DSMT: 10 hours first year ___ Follow up |
|information: |DSMT: 2 hrs each following year |
| |___Additional training: _____hrs requested ___ Renal Disease |
| |Group: 3 hours first year |
| | |
|Referring |I certify that diabetes self-management/medical nutrition therapy |
|Physicians |education is needed under a comprehensive plan to promote adherence |
|Order |with therapy and achievement of skills and knowledge to manage diabetes|
| |or renal disease for this patient Comprehensive plan includes diet, |
| |exercise, education, monitoring, group training and follow-up |
| | |
| |Physicians Name___________________________________ Phone______________|
| |Fax_______________
|
| |Please Print |
| | |
| |Physicians Signature _____________________________________________ |
| |Date ____________________ |
|Fax To: |Oklahoma Diabetes Center at the OU College of Medicine |
| |920 Stanton L Young Blvd, WP1345 |
| |Phone: 405 271-3455 |
| |Oklahoma City, OK 73104 |
| |Fax: 405 271-7522 |
| |This original copy should be placed in the patients medical record |
February 2007
