Download Tallahassee Memorial Diabetes Center 1981 Capital Circle, NE

Tallahassee Memorial Diabetes Center
1981 Capital Circle, NE
Tallahassee, FL 32308
(850) 431 - 5404 / (850) 431 – 4794
Pediatric Referral
Date: ________________
To: Referral Desk ______________ pages including this cover sheet
I am referring this patient for medically necessary outpatient self-management training
Patient Information:
Patient Name: ___________________________________________________________________
Parent / Guardian Name(s): ________________________________________________________
Home Phone _________________ Cell __________________ Work _______________________
Name of person to contact _____________________ Relationship: _________________________
Patient’s dob __________ Sex: ______________________ SS#: ___________________________
Mailing Address: ____________________________________________
Insurance Coverage: ___________________________________ ID# ______________________
Does this child have CMS? _________ (If yes, please remember to inform them about this referral)
Which location?
Tallahassee
Panama City
Valdosta
Albany
I CERTIFY THAT THE DIABETES SELF-MANAGEMENT/MEDICAL NUTRITION THERAPY EDUCATION
SERVICES ARE NEEDED UNDER A COMPREHENSIVE PLAN FOR THIS PATIENT’S CARE.
Physicians Order:
Diabetes Management
Nutrition
Sensor Study / Trial
Pump Start / Trial – specific pump _____________________________________
Patient’s Diagnosis: ___________________________________ ICD9: _________________________
Contact Person: _______________________________________________________________________
Phone: ___________________________________ Fax: ______________________________________
Physician Signature: ___________________________________________________________________
*CONFIDENTIALITY NOTE*
The information contained in this e-mail is intended for the personal and confidential use of the designated recipient(s) named
above. This message may be an attorney/client or physician/patient communication, and as such, is privileged and confidential. If
the reader of this message is not the intended recipient, you are hereby notified that you have received this message in error, and
that any error, discemination, distribution, or copying of this message is strickly prohibited. If you have received this e-mail
communication in error, please notify my by telephone. Thank you.
Last Revided 2-3-05
TALLAHASSEE MEMORIAL DIABETES CENTER
MEDICARE PATIENT REFERRAL ATTACHMENT
In keeping with Medicare requirements, this form must be completed and submitted
with the Referral Form for each of your Medicare patients.
Patient Name: _____________________________________ DOB: ____________________________
DIABETES SELF-MANAGEMENT EDUCATION/TRAINING (DSME/IT)
Check typo of training services and number of hours requested:
Initial group DSME/T: 10 hours or ______ no. hrs. requested
Follow up DSME/T: 2 hours or ______ no. hrs. requested
PATIENTS WITH SPECIAL NEEDS REQUIRING INDIVIDUAL (1 ON 1) DSME/T
Check all special needs that apply:
Vision
Hearing
Requested _________
Physical
Cognitive Impairment
Language Limitations
Other ____________________________
Additional Training
Additional hrs.
DSME/T CONTENT
Please check below the appropriate content checking box:
Comprehensive diabetes education (all content areas)
Or
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 GDM
Prevent, detect and treat chronic complications
MEDICAL NUTRITION THERAPY (MNT) FOR PATIENTS WITH DIABETES
Check the type of MNT and/or number of additional hours requested:
Initial MNT
3 hours or
_________ no. hrs. requested
Annual follow up MNT
2 hours or
_________ no. hrs. requested
Additional MNT services in the same calendar year per RD
Additional hrs. requested ____________________________
Please specify change in medical condition, treatment and/or diagnosis:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Medicare coverage of DSMT and MNT requires the physician to provide documentation of a diagnosis of
diabetes based on one of the following:



A fasting blood sugar greater than or equal to 126 mg/dl on 2 different occasions;
A 2 hour post-glucose challenge greater than or equal to 200 mg/dl on 2 different occasions; or
A random glucose test over 200 mg/dl for a person with symptoms of uncontrolled diabetes
Medicare Coverage:
DSME/T: 10 hrs initial DSME/T in a 12-month period from the date of first visit; 2 hrs each calendar year following the year in
which initial training was completed.
MNT: 3 hrs initial MNT in the first calendar year, plus 2 hrs follow-up MNT annually. Additional MNT hours are available for
change in medical condition, treatment and/or diagnosis.
Signature ____________________________ NPI# ____________________________ Date ___________
(Note: Medicare requires a physician signature when MNT is ordered.)