Referral Form - Christiana Care Health System
Referral Form - Christiana Care Health System
Referral Form - Christiana Care Health System
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Eugene DuPont Preventive Medicine & Rehabilitation InstituteDepartment of Family and Community Medicine3506 Kennett PikeWilmington, Delaware 19807(302) 661-3000 Phone(302) 661-3010 Faxhttp://www.christianacare.org/pmri<strong>Referral</strong> <strong>Form</strong>Educational Outreach & Disease ManagementPlease provide to the patient &/or Fax to (302) 661-3010Diabetes Educationo Living with Diabetes (Group class)- Comprehensive 8 hour program; includes diabetes overview, target blood sugars, medication compliance, nutrition and activityExercise Services/Medical Fitnesso Fitness evaluation and consultation for individualized exercise program- Comprehensive assessment covers fitness components of aerobic capacity, body composition, flexibility, muscle strength, and muscleendurance. Results incorporated in developing individualized exercise prescriptiono Guided/supervised exercise program at PMRI- Focus is on higher-health risk individuals. Periodic reviews and short-term goal setting scheduled every 3-months with new goals andprogram adjustments establishedo Pulmonary Rehabilitation Program- Comprehensive 12 week program monitored by Respiratory Therapist and Exercise PhysiologistIndividual Nutritional Counselingo Medical Nutrition Therapy (MNT) – Diabetes and Other Appropriate Dx.- Individual meal planning and goal setting<strong>Health</strong> Psychology Counselingo Individual Counseling SessionPatient InformationName: ____________________________________________________DOB: _________________Phone: ______________________________Diagnosis Code:_______________Additional Information (e.g. History; Recommendations/Restricitions; A1C, recent labs/tests)Medicare Benefits:Both DSMT and MNT may be ordered in the same year.Allow 10 hours of initial group instruction in a 12 month period, plus 2 hours of follow-up training annually.Allow 3 hours of initial MNT in first calendar year, plus 2 hours annuallyAdditional MNT hours available for change in medical condition, treatment or diagnosisThe patient indicated above has been medically examined and deemed appropriate for participation in the program/service marked above._______________________ ________________________ _________________________Provider Signature/Date Provider Printed Name Provider Phone no/fax no.
Eugene DuPont Preventive Medicine & Rehabilitation InstituteDepartment of Family and Community Medicine3506 Kennett PikeWilmington, Delaware 19807(302) 661-3000 Phone(302) 661-3010 Faxhttp://www.christianacare.org/pmri<strong>Referral</strong> <strong>Form</strong>, page 2Educational Outreach & Disease ManagementPlease provide to the patient &/or Fax to (302) 661-3010Additional <strong>Referral</strong> InformationIf you are referring your patient for the Living with Diabetes group class OR Medical Nutrition Therapyplease include the following:o Copy of most recent labs to include hemoglobin A1co Blood sugar at diagnosis (if newly diagnosed)o Reason for referralo Copy of Medical Insurance cardsIf you are referring your patient to Exercise Services/Medical Fitness please include the following:o Recommendations or restricitions appropriate for your patient’s participationo Signature of consent for participationIf patient is uninsured please contact us for coverage/payment options
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