Patient Name:

Medical Record Number:
Date of birth:

Patient home phone number:

Patient work phone number:

 

All sections must be completed to ensure patient's eligibility for insurance coverage of training program.

Gender:  Male   Female

DM: Type 1   Type 2  

ICD9 Code

One or more of the following reasons must be specified as reason(s) for referral to Group Diabetes Self Management Training Classes:

New Onset Diabetes;

Poor glycemic control as evidenced by HbA1c of 8.5% or more in the past 90 days

Change in treatment regimen

    From no diabetes medications to diabetes medication

    From oral diabetes medication to insulin

High risk for complications based on poor glycemic control

    Documented acute episodes of severe hypoglycemia

    Acute severe hyperglycemia occurring in the past year during which patient required third party assistance for either emergency room visit or hospitalization

Kidney complications related to diabetes and manifested by albuminuria

Unique circumstances: Please specify: 

Lab reports and date

Hemoglobin A1c:

Triglycerides:

Total cholesterol:

LDL:

HDL:

 

REFERRING PHYSICIAN : _ Pager #:

Phone #: Fax #:

Specialty:

Email:

For questions please contact:

Andrea Conner RD, CDE, Diabetes Program Coordinator
310-749-1503 aconner@mednet.ucla.edu