Partners in Nutrition and Diabetes Education Registration: (970) 613-4106
1113 N. Cleveland Ave. Loveland, CO 80537 Office: (970) 622-9997
DIABETES SELF-MANAGEMENT TRAINING (DSMT) &
MEDICAL NUTRITIONAL THERAPY (MNT) REFERRAL FORM
Diabetes self-management training (DSMT) and medical nutrition therapy (MNT) are individual and complementary services
to improve diabetes care. Research indicates MNT combined with DSMT improves outcomes.
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Patient Name:___________________________________________________________Date of Birth:________________________
Address:__________________________________________________________________________________________________
Phone Number(s): home:______________________Work:________________________Other:_____________________________
PLEASE CIRCLE ALL DIAGNOSIS THAT APPLY:
New Onset Diabetes Existing Diabetes,______number of years
Type 1 unspecified 250.01
Type 2 unspecified 250.00
Type 1 uncontrolled 250.03
Type 2 uncontrolled 250.02
Categories of Increased Risk for Diabetes: (pre-diabetes; impaired fasting glucose; impaired glucose tolerance; A1C range 5.7- 6.4%)
Hyperglycemia NOS 790.29
Impaired fasting glucose 790.21
Impaired glucose tolerance test 790.22
Gestational Diabetes 648.83
Other _______________________________________________________________________
Complications Related to Diabetes: Associated Health Disorders:
Diabetes with ketoacidosis 250.10 Hypertension 401.9
Diabetes with hypoglycemia 250.82 Hyperlipidemia 272.4
Diabetes neurological manifestations 250.60 Obesity 278.00
Diabetes peripheral circulatory disorders 250.70 Hypothyroid 244.9
Diabetes with ophthalmic manifestations 250.50 Other__________________________________________
Diabetes with renal manifestations 250.40
PLEASE CIRCLE ALL ORDERS THAT APPLY:
Diabetes Self-Management Training: Group or Individual
Group or individual education sessions are available. Comprehensive diabetes education based on AADE 7 Self-Care behaviors:
*Healthy eating *Being Active *Monitoring *Taking Medication *Problem Solving *Healthy Coping *Reducing Risks
Medical Nutritional Therapy(*M.D. NPI # required)
Other Services:
Glucose Monitoring
Insulin start: Type__________________units______________ Type___________________units__________________
Insulin Pump training (please provide pump rates)
CDE may adjust insulin & will notify health care provider
FOR PATIENT ELIGIBILITY & OUTCOMES MONITORING,
PLEASE FAX THIS FORM WITH PROGRESS NOTES & COPIES OF RECENT LABS TO: 970-667-8383
Print name of referring health care provider:______________________________________________________________________
Signature of referring health care provider:________________________________________________Date:__________________
*NPI # (required for MNT)_________________________Referring health care provider phone#:____________________________
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Chris Book, RD, CDE Kathy Enyeart, RN, BS, CDE Jackie Nielsen, MS, RD, Mary M. Hawkins, FNP-BC, ADM, CDE
