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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.)