Diabetes Self Management Education Training Order Form

Patient Information

Last Name First Name Middle

Home Phone Number Other Phone Number

Diagnosis (Patient must have a diagnosis of diabetes)

COMPLICATIONS/COMORBIDITIES - Check all that apply

Diabetes Self-Management Education/Training (DSME/T)CHECK THE TYPE OF TRAINING SERVICES AND NUMBER OF HOURS REQUESTED

Initial group DSME/T: 10 hours or number hours requested

Follow-up group DSME/T: 2 hours or number hours requested

DSME/T CONTENT

Monitoring Diabetes Nutritional Management Medications

Diabetes as Disease Process Goal Setting, Problem Solving Physical Activity

Psychological Adjustment Prevent, Detect, and Treat Acute Complications Other (Specific Training)___________________

Fax To: East Hawaii IPA (808) 935-4472Please attach: Most Recent Medication List Most Recent Labs Most Recent Notes on Diabetes Consultation Demographic Sheet

Signature Date

NPI #

Group/Practice Name Address Phone Number

For questions or additional information, please call (808) 797-3113.

Revised 7/2017 by Puna Plantion LTD dba KTA Puainako Pharmacy

Hypertension

Neuropathy

Kidney Disease

CHD

Dyslipidemia

Retinopathy

Pregnancy

Mental/Affective Disorder

Stroke

PVD

Obesity

Other: __________

Type 1 Type 2 Gestational Diagnosis Code: _____