Get Diabetes Smart Add/remove Form - Cencal Health

The Diabetes SMART Add/Remove Form for CenCal Health is a crucial document for managing patient eligibility in the Diabetes SMART program. This guide provides a clear and supportive approach to help users fill out the form accurately and efficiently online.

Follow the steps to successfully complete the form online:

1. Press the ‘Get Form’ button to access the Diabetes SMART Add/Remove Form and open it in your preferred editing software.
2. Enter the primary care provider (PCP) name and their contact phone number in the designated fields.
3. Fill in the name of the person completing the form along with the date of the request.
4. Provide the member’s details including their name, phone number, member ID number, and date of birth in the respective sections.
5. Indicate whether you are adding or removing the member by selecting the appropriate option.
6. In the provided fields, state the reason for adding or removing the member with specificity. Possible reasons include the diagnosis of diabetes, prescription information, or lifestyle management.
7. If necessary, include additional details to validate the decision regarding the member’s inclusion or removal from the Diabetes SMART Program, including any relevant medical documentation.
8. Complete the section for the PCP requesting the change and add the date.
9. Understand that there is a section labeled 'Please Do Not Write in Box Below' where eligibility determinations will be made after your submission.
10. Save your changes and download, print, or share the completed form as needed.

Take action now and complete your documents online to ensure efficient program management.