Core Clinical Care / Apple Diabetes Center	Fax: 410-860-1155
Diabetes Self-Management Education/Training and Medical Nutrition Therapy Services Order Form

Patient Information

Patient’s Last Name			First Name		Middle		
Date of Birth	/	/_______	Gender:	Male	Female		
							
Address			City		State	Zip Code	
							
Home Phone			Other Phone		E-mail address		

Diabetes self-management education and training (DSME/T) and medical nutrition therapy (MNT) are individual and complementary services to improve diabetes care. Both services can be ordered in the same year. Research indicates MNT combined with DSME/T improves outcomes.

Diabetes Self-Management Education/Training (DSME/T)

Check type 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	
Telehealth			
			
Patients with special needs requiring individual (1 on 1) DSME/T			
Check all special needs that apply:			
Vision	Hearing	Physical	
Cognitive Impairment	Language Limitations		
Additional training	additional hrs requested ___________		
Telehealth	Other ____________________________		
			
DSME/T Content			
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		

Medicare coverage: 10 hrs initial DSMT in 12 month period from the date of first class or visit

DIAGNOSIS

Please send recent labs for patient eligibility & outcomes monitoring

Type 1	Type 2		
Gestational	Diagnosis code ___________________		
			
Complications/Comorbidities			
Check all that apply:			
Hypertension	Dyslipidemia	Stroke	
Neuropathy	PVD		
Kidney disease	Retinopathy	CHD	
Non-healing wound	Pregnancy	Obesity	
Mental/affective disorder	Other ____________________________		

Medical Nutrition Therapy (MNT)

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	
Telehealth	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: 3 hrs initial MNT in the first calendar year, plus 2 hrs follow-up MNT annually. Additional MNT hours available for change in medical condition, treatment and/or diagnosis.

Definition of Diabetes (Medicare)

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 two 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. 

Source: Volume 68, #216, November 7, 2003, page 63261/Federal Register.

Other payors may have other coverage requirements.

Signature and NPI # _____________________________________________________________________  Date	/_______/_______

Group/practice name, address and phone: ___________________________________________________________________________________________

Revised 8/2011 by the American Association of Diabetes Educators and the American Dietetic Association.

Community Pharmacy Foundation | GTwigg - Grant #143 | http://www.communitypharmacyfoundation.org/grants/grants_list_details.asp?grants_id=70981