Get Diabetes And Nutrition Counseling Referral Form - St Charles - Physicianfinder Scmc

Filling out the Diabetes And Nutrition Counseling Referral Form is a crucial step in helping patients access necessary diabetes and nutrition counseling services. This guide will provide users with a clear, step-by-step approach to completing this form online, ensuring a smooth process for all involved.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to access the Diabetes And Nutrition Counseling Referral Form and open it in your preferred editor.
2. Complete the 'Patient and Insurance Information' section by providing the patient's name, date of birth, phone number, social security number, insurance name, subscriber ID, and authorization number. Ensure accuracy as this information is vital for billing and appointment scheduling.
3. Indicate the 'Number of Visits' required and select the location where the service will be provided from the options available (SC Bend, SC Madras, SC Prineville, SC Redmond).
4. Fill in the 'Diagnoses / Reason(s) for Referral' section by entering the appropriate ICD 10 Code and selecting any relevant diagnoses from the provided list, marking both primary and secondary diagnoses as necessary.
5. In the 'Services to be Performed' section, check the boxes next to the specific services requested for the patient. Ensure to note any additional services that may be required.
6. Complete the 'Clinical Data' section by entering the patient’s vital statistics such as blood pressure, height, fasting glucose, HbA1C, total cholesterol, LDL, HDL, triglycerides, weight, OGTT, and confirm if the patient is okay to exercise.
7. Identify any 'Special Learning Needs' the patient may have that could affect their participation in group classes. Specify the nature of these needs.
8. Provide your authorization as the physician or healthcare provider in the 'Physician / Healthcare Provider Authorization' section by signing and dating the form.
9. Once all sections have been completed, save your changes. You can then download or print the form to retain a copy for your records.
10. Finally, fax the completed form to the provided number (541-706-4929) to schedule the patient's appointment.

Complete the Diabetes And Nutrition Counseling Referral Form online to help your patients receive timely care.