Get the free OCHD DSME Referral Form AND Instructions 18SEPT15doc - orangecountync

Orange County Health Department 2501 Homestead Road; Chapel Hill, NC 27516 Orange County Health Department 300 W. Bryon Street; Hillsborough, NC 27278 Diabetes Self-management Education Program REFERRAL

How to fill out ochd dsme referral form

How to fill out ochd dsme referral form:

1. Start by providing your personal information, such as your full name, address, phone number, and email address. Make sure to double-check for accuracy.
2. Next, indicate your date of birth and any relevant medical conditions or diagnoses that require you to seek DSME (Diabetes Self-Management Education).
3. Specify the name and contact details of your healthcare provider who is referring you for this DSME program. Include their name, address, phone number, and email address.
4. In the form, there may be a section where you need to provide information about your insurance coverage. Include your insurance company's name, policy number, and any additional details relevant to your coverage.
5. Indicate your preferred language for the DSME program. This ensures that the materials and instructions will be provided to you in a language you understand.
6. If you have any specific goals or expectations for the DSME program, mention them in the designated section. This can help the educators tailor the program to better meet your needs.
7. Read through the form carefully, ensuring that all the required fields are filled out accurately. If there are any optional sections, decide whether you want to provide additional information.

Who needs ochd dsme referral form:

1. Individuals with diabetes who are interested in enrolling in a DSME program to learn more about managing their condition effectively.
2. Healthcare providers who identify a need for their patients with diabetes to receive additional education and support through DSME.
3. Insurance providers who require participants to fill out the referral form as part of the pre-authorization process or to verify eligibility for coverage of the DSME program.

Remember, the ochd dsme referral form is typically filled out by both individuals seeking DSME and their healthcare providers to facilitate enrollment in the program and ensure appropriate coverage and support.

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What is ochd dsme referral form?

The OCHD DSME referral form is a document used to refer individuals to the OCHD Diabetes Self-Management Education program.

Who is required to file ochd dsme referral form?

Healthcare providers, caregivers, or individuals themselves may be required to file the OCHD DSME referral form.

How to fill out ochd dsme referral form?

To fill out the OCHD DSME referral form, one must provide the necessary personal and medical information of the individual being referred.

What is the purpose of ochd dsme referral form?

The purpose of the OCHD DSME referral form is to facilitate the enrollment of individuals in the Diabetes Self-Management Education program.

What information must be reported on ochd dsme referral form?

The OCHD DSME referral form may require information such as the individual's name, contact information, medical history, and insurance details.