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DIABETES PREVENTION PROGRAM Referral Form PATIENT NAME DATE BIRTH DATE PHONE EMAIL ADDRESS CITY STATE My BMI (Body mass Index) is ? 25 kg/m2. ZIP HEIGHT CURRENT WEIGHT Please check off applicable
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How to fill out diabetes prevention program referral

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How to fill out diabetes prevention program referral:

01
Begin by gathering the necessary information: You will need the patient's name, address, phone number, and date of birth.
02
Next, fill in the healthcare provider's information: Include their name, address, phone number, and any other required contact details.
03
Indicate the reason for the referral: In this case, specify that it is for the diabetes prevention program.
04
Provide any relevant medical history: Include details about the patient's current health status, any pre-existing conditions, and any medications they may be taking.
05
Include any additional information: If there are any specific concerns or instructions for the diabetes prevention program, make sure to include them in this section.
06
Sign and date the referral: Ensure that you have completed all the necessary fields and then sign and date the referral form.

Who needs diabetes prevention program referral?

01
Individuals at high risk of developing diabetes: People who have been diagnosed with prediabetes or have risk factors such as obesity, high blood pressure, or a family history of diabetes may benefit from a referral to the diabetes prevention program.
02
Healthcare providers: Doctors, nurse practitioners, or other healthcare professionals may suggest or refer patients to participate in a diabetes prevention program based on their assessment of the patient's risk factors and health status. Referral is important for connecting patients with the appropriate resources and support to prevent or delay the onset of diabetes.
Remember, it is crucial to follow any specific guidelines or referral procedures set by your healthcare organization or insurance provider when filling out a diabetes prevention program referral.
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Diabetes prevention program referral is a process where individuals at risk for diabetes are referred to programs and services aimed at reducing their risk.
Healthcare providers, insurance companies, and public health departments may be required to file diabetes prevention program referrals.
Diabetes prevention program referrals may be filled out online, by phone, or through a healthcare provider.
The purpose of diabetes prevention program referral is to help individuals at risk for diabetes access resources and support to prevent or manage the condition.
Information such as the individual's demographics, risk factors for diabetes, and referral source may need to be reported on the referral form.
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