Get A Referral Form - Valley Of The Sun Ymca

This guide provides clear and supportive instructions for completing the A Referral Form for the Valley Of The Sun YMCA online. By following these steps, users can ensure that all necessary information is correctly submitted to gain access to the YMCA's Diabetes Prevention Program.

Follow the steps to complete the A Referral Form with ease.

1. Click the ‘Get Form’ button to access the referral form online and open it in your preferred document editor.
2. Fill in the participant's name, date of birth, phone number, and email address in the designated fields.
3. Enter the Medicare ID number if applicable.
4. Indicate if Spanish-speaking assistance is required.
5. Ensure the participant meets the qualification criteria: they must be at least 18 years old, have a Body Mass Index (BMI) of 25 or greater (22 or greater if Asian), and if they are 65 and on Medicare, they must have verified prediabetes.
6. The healthcare provider should input the participant's height and weight to calculate the BMI.
7. Check the appropriate boxes to identify the prediabetes information, including Hemoglobin A1C percentage and fasting plasma glucose.
8. The healthcare provider must indicate their recommendation for participation in the Diabetes Prevention Program by checking the appropriate option.
9. The healthcare provider should sign and date the form, and fill in their name and contact information.
10. The patient needs to sign the authorization to release health information, confirming their understanding and consent.
11. Once all sections are completed, users can save changes, download, print, or share the form as needed.

Complete the A Referral Form online today to take the first step towards participating in the YMCA’s Diabetes Prevention Program.