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DURHAM REGIONAL DIABETES PROGRAM REFERRAL FORM Patient Name: M F DOB (dd×mm/by): Age: Parent×Guardian (if less than 18 years of age): Health Card #: Address: Phone (Home): Phone (Work): Phone (Cell):
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How to fill out durham regional diabetes program
How to Fill Out Durham Regional Diabetes Program:
01
Obtain the necessary forms: Start by contacting the Durham Regional Diabetes Program or visiting their website to request the required forms. They may also have the forms available for download online.
02
Complete personal information: Begin by filling out the personal information section of the form. This typically includes your full name, contact information, date of birth, and health card number.
03
Provide medical history: The next step is to provide your medical history related to diabetes. This may include information about your diagnosis, medications, treatment plans, and healthcare providers involved in your diabetes management.
04
Include demographic information: Some forms may ask for additional demographic information such as your race, ethnicity, income level, and household size. This information is often used for statistical purposes and to help identify any disparities or trends within the population.
05
Consent and authorization: Read through the consent and authorization section carefully and provide any necessary signatures. This section usually outlines how your personal health information will be used and shared within the Durham Regional Diabetes Program.
06
Submit the completed form: Once you have filled out all the required sections, review the form for accuracy and completeness. Make sure you haven't missed any required fields or signatures. Then, submit the form according to the instructions provided. This may involve mailing it to a specific address, faxing it, or submitting it online through a secure portal.
Who needs Durham Regional Diabetes Program?
01
Individuals with diabetes: The Durham Regional Diabetes Program is primarily designed for individuals who have been diagnosed with diabetes. This includes both type 1 and type 2 diabetes.
02
Caregivers and family members: The program may also be beneficial for caregivers and family members of individuals with diabetes. It can provide education, support, and resources to help them better understand and assist in managing the condition.
03
Healthcare professionals: Healthcare professionals who are involved in the care and treatment of individuals with diabetes can also benefit from the Durham Regional Diabetes Program. The program may offer training, guidelines, and collaborative opportunities to ensure optimal diabetes management for their patients.
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What is durham regional diabetes program?
Durham Regional Diabetes Program is a program aimed at providing support and resources for individuals with diabetes in the Durham region.
Who is required to file durham regional diabetes program?
Healthcare providers, clinics, and organizations involved in diabetes care are required to file the Durham Regional Diabetes Program.
How to fill out durham regional diabetes program?
You can fill out the Durham Regional Diabetes Program by providing information about your diabetes care services, patient demographics, and outcomes.
What is the purpose of durham regional diabetes program?
The purpose of Durham Regional Diabetes Program is to improve the quality of care for individuals with diabetes, track outcomes, and identify areas for improvement.
What information must be reported on durham regional diabetes program?
Information such as number of patients served, types of services provided, patient outcomes, and follow-up care must be reported on Durham Regional Diabetes Program.
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