Diabetes Self Management Training Insulin Pump Follow Up

Size: px
Start display at page:

Download "Diabetes Self Management Training Insulin Pump Follow Up"

Transcription

1 701 East Marshall Street, West Chester, PA Diabetes Self Management Training Insulin Pump Follow Up Patient Name: Visit Date: Time: To prepare for your Diabetes Self Management Training Follow up Session, please read the following information: 1. Please check with your insurance company to determine your benefits for Diabetes Self Management Training Follow up. Attached in this packet you will find a list of questions to assist you in talking with your insurance provider. 2. Please bring the following items to your appointment: Your insurance card. Your insurance referral or referral number if your insurance company requires referrals. If you do not have a referral the day of your visit, your appointment may need to be rescheduled. A doctor s prescription for Diabetes Self Management Training Follow up, or Pump Follow up that also states your diagnosis. A signed waiver form (enclosed); this form must be signed before the service is rendered. The co pay required by your insurance; this amount should be listed on your insurance card, or your insurance company can provide this information. Completed Registration Form (enclosed) Completed Staying on Track Insulin Pump Therapy Follow up questionnaire (enclosed) Your blood glucose meter and your blood glucose log. 3. If you are not approved for coverage, please be advised that you will receive a bill for services provided. This service is located at the Fern Hill Medical Campus, 915 Old Fern Hill Road in West Chester. Come to the main entrance for Buildings A and B and your class will be in the Wellness Resource Center Classroom. If you need to cancel and/or reschedule your appointment, please call within 24 hours of your appointment. 07/10

2 Insurance Provider Questions 1. Please check with your insurance company to determine your benefits for Diabetes Self Management Training and/or Medical Nutrition Therapy. Listed below you will find a list of questions to assist you in talking with your insurance provider. Is this service covered under my policy? Would a referral be needed for this service? Is a pre authorization/pre certification needed prior to me attending this program? If a policy has a deductible, can this service be applied against my deductible? Does this service require a co pay and/or co insurance? What out of pocket expense can I anticipate with this service? 2. If you are not approved for coverage, please be advised you will receive a bill for services provided. Financial arrangements can be made through The Chester County Hospital business office. 1/07

3 Diabetes Self Management Program INSURANCE WAIVER FORM DIABETES SELF MANAGEMENT TRAINING SERVICES Notice from The Chester County Hospital Your doctor has ordered Diabetes Self Management Training. Your insurance carrier (Medicare, and/or other insurance or HMO) will only pay for services that it determines to be reasonable and necessary. If your insurance carrier determines that a particular service, although it would otherwise be covered, is not reasonable and necessary under their standards, it is likely to deny payment for Diabetes Self Management Training for the following reasons: Diabetes Self Management Training is not a covered service You have already exhausted your benefit for Diabetes Self Management Training Please note that The Chester County Hospital will work with your insurance provider to obtain reimbursement for Diabetes Self Management Training Services. According to Act 98 of 1998, insurance providers licensed to provide insurance in Pennsylvania were mandated to cover diabetes self management training/education. If your provider is a self insured plan, however, this service may not be listed as a covered service. Beneficiary Agreement In the event that The Chester County Hospital is notified that my insurance denies payment for Diabetes Self Management Training for the reasons stated above, I agree to be personally and fully responsible for payment. I further understand that I am responsible for any deductibles or co pays required by my insurance provider. Patient s Signature Registrar s Signature Date You may refer to Section 1862(A)(1) of the Medicare law for more information. Admin:ABN July /10

4 Registration Form Patient Information: Patient Name: Date of Birth: Social Security Number: Primary Language: Street Address: City: State: Zip Code: Home phone: Work Phone: Cell phone: Address: Employer: Emergency Contact Name: Phone Sex: Male Female Marital Status: Single Married Divorced Widowed Latex allergy: (circle) Yes No Ethnicity: Religion: Medical Information: Name of Primary Care Physician: Name of Ordering Physician: Ordering Physician Address: City: State: Zip: Phone: Insurance Information: Primary Insurance: Policy #: Group Policy Holder s Name: Relationship to Patient: Policy Holder Date of Birth (if other than patient Secondary Insurance: How did you hear about this program? Doctor Friend Promotional Material Other:

5 Staying on Track Insulin Pump Follow up Questionnaire Please complete the following: Name: Date: Birth date: Ordering Physician: Check if done Date Date HbA1c test Dental Exam Cholesterol Dilated Eye Exam Urine test for protein Pneumonia vaccine Flu shot Foot exam Have you been hospitalized since you last attended a diabetes self management program? No Yes Reason: Have you lost any time from work related to your diabetes management? Yes No How often do you see the health care provider who manages your diabetes? Monthly every 2 3 months every 6 months other: Current Medications (including vitamins and supplements); feel free to bring list to photocopy: Do you take an aspirin daily? Yes No Do you take an ACE inhibitor/arb Yes No Don t Know Do you take your medications as prescribed? Yes No; Why not? Diabetes Management: Insulin Pump: Name/Model # pump: How long have you been on this pump? Current Basal rates: 12 a.m. Insulin to carbohydrate ratios: Breakfast Lunch Dinner Snacks Correction/sensitivity factor: Insulin action curve: (circle one) Target range(s): 12 a.m. Insulin Used : (circle one) Humalog Novolog Apidra Regular Infusion set: Silhouette Quick Set Sure T Soft set Other Infusion set change: (how often do you change your set, check what applies): change every two days change every three days greater than three days Sites used: abdomen thigh outer hip/buttocks area arms other: 11/17/09

6 Staying on Track Insulin Pump Follow up Questionnaire Insulin Pump Evaluation: Do you use advanced features of the pump? Yes No If yes, what features do you use? (Check those that apply) extended bolus dual/square wave temporary basal patterns easy bolus Software: Do you currently use the data management software to upload or download your pump information into a computer? Yes No If yes, what program? Glucose testing What type of glucose meter do you have? Do you use a diabetes supply company? ; If yes, what company? How often do you test your sugar levels? times /day, week, month (circle) When do you test your glucose? Do you currently download your meter? Yes No What software program do you use: Do you use a Continuous glucose monitoring system? Yes No If yes, which system? Medtronic DexCom Navigator How often do you change the sensor? Sites used for sensor insertion: How often do you calibrate the system? Do you wear the system consistently? Yes No Occasionally Hypoglycemia (low blood sugar) Do you experience episodes of hypoglycemia (glucose <70 mg/dl)? Yes No If yes, how often do you have lows? Do you have glucose levels below 70 that you do not feel? Yes No How do you treat your low glucose reactions? Have you experienced any severe low glucose reactions that required the assistance of someone else? Yes No Do you have a Glucagon emergency kit? Yes No Do you have a medical ID tag? Yes Hyperglycemia (high blood sugar) Reminder: Glucose target ranges: <110 mg/dl before meals; <140 mg/dl, 2 hours after meals Based on above target ranges, how often is your glucose in target? <10% 26 50% % 11 25% 51 75% I don t know If you experience high glucose readings, when do these tend to occur? First thing in the morning (fasting) After meals: (circle) breakfast, lunch, dinner, all Before meals: (circle) lunch, dinner Before Bedtime Other: When your glucose is over 250mg/dl two times in a row do you check for ketones? Yes No; If no, do you know how to check for ketones? Yes No Do you take insulin by injection to correct high blood sugars during these times? Yes No Do you carry a syringe or insulin pen on you at all times? Yes No Why do you think you experience high glucose reactions at these times? 11/17/09

7 Staying on Track Insulin Pump Follow up Questionnaire Meal Planning What % of the time are you following your meal plan? <10% 26 50% % 11 25% 51 75% I don t have a meal plan Do you count carbohydrates? Yes No When was the last time you met with a dietitian for meal planning? Less than 1 year More than one year Greater than 5 years Have you tried any other diets or meal plans since you last attended a diabetes education program? Yes No; if yes, list: Exercise Do you currently exercise? Yes No If No, why not? If Yes, please describe: Type: How often (days/week): How many minutes: Is this activity level: more than less than, or unchanged since your previous visit? Do you adjust your pump settings when you exercise? Yes No Do you suspend your pump or take it off when you exercise? Yes No If yes, what is the average time? Risk Reduction Do you smoke? Yes No; If yes are you interested in attending a smoking cessation program? Yes No Maybe Have you ever been evaluated for depression? Yes No If yes, have you ever received treatment for depression? Medication/Counseling/Other Yes No; if yes explain: What variables or factors, if any, do you feel interfere with your ability to manage your diabetes? (i.e. money, time, stress, lack of support, depression, etc.) What pump issues or concerns would you like to have addressed in this education session? Thank You 11/17/09

Borgess Diabetes Center PATIENT REGISTRATION/DEMOGRAPHICS

Borgess Diabetes Center PATIENT REGISTRATION/DEMOGRAPHICS Borgess Diabetes Center PATIENT REGISTRATION/DEMOGRAPHICS Please complete the following form by filling in the blanks or by circling the answer provided. Last Name: First Name M.I. Address: City, State,

More information

OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON DIABETES MEDICAL MANAGEMENT PLAN Page 1 of 5 TO BE COMPLETED BY PARENT OR GUARDIAN

OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON DIABETES MEDICAL MANAGEMENT PLAN Page 1 of 5 TO BE COMPLETED BY PARENT OR GUARDIAN PART I OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON DIABETES MEDICAL MANAGEMENT PLAN Page 1 of 5 TO BE COMPLETED BY PARENT OR GUARDIAN Student School Date of Birth Date of Diagnosis Grade/ Teacher Physical

More information

Diabetes Health Care Plan

Diabetes Health Care Plan The Public Schools of Brookline School Health Services of Plan: Diabetes Health Care Plan To be completed by the student s health care team and parents/guardian. Plan will be kept with the school nurse

More information

Diabetes Self-Management Questionnaire

Diabetes Self-Management Questionnaire Diabetes Self-Management Questionnaire Name: Date: Date of Birth: / / Gender: F M Address: Street City State Zip Phone: Home ( ) Work: ( ) Mobile: ( ) Ethnic Background: White/Caucasian Black/A-A Hispanic

More information

ALVIN INDEPENDENT SCHOOL DISTRICT Diabetes Medical Management Plan

ALVIN INDEPENDENT SCHOOL DISTRICT Diabetes Medical Management Plan ALVIN INDEPENDENT SCHOOL DISTRICT Diabetes Medical Management Plan of Plan: School Year (must be current): This plan should be completed by the student s personal health care team and parents/guardian.

More information

Telephone: Home Work Cell E-mail Address Father/Guardian: Address:

Telephone: Home Work Cell E-mail Address Father/Guardian: Address: SAMPLE Diabetes Medical Management Plan/Individualized Healthcare Plan Part A: Contact Information must be completed by the parent/guardian. Part B: Diabetes Medical Management Plan (DMMP) must be completed

More information

School Year 20 / 20. Diabetes Health Care Plan for Southgate Schools

School Year 20 / 20. Diabetes Health Care Plan for Southgate Schools School Year 20 / 20 Diabetes Health Care Plan for Southgate Schools Diabetes Medical Management Plan, Initialized Healthcare Plan and Physician Orders Part A: Contact Information must be completed by the

More information

Health Professional s. Guide to INSULIN PUMP THERAPY

Health Professional s. Guide to INSULIN PUMP THERAPY Health Professional s Guide to INSULIN PUMP THERAPY Table of Contents Introduction Presenting Insulin Pump Therapy to Your Patients When Your Patient Chooses the Pump Estimates for Starting Insulin Pump

More information

FHUSD Diabetic Management Plan

FHUSD Diabetic Management Plan This plan should be completed by the student s personnel Physician or Licensed Healthcare Provider and parent/guardian. It should be reviewed with relevant school staff and copies should be kept in a place

More information

Diabetes Medical Management Plan (DMMP)

Diabetes Medical Management Plan (DMMP) Diabetes Medical Management Plan (DMMP) This plan should be completed by the student s personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant school staff

More information

Diabetes Management and Treatment Plan for School (For the insulin pump student)

Diabetes Management and Treatment Plan for School (For the insulin pump student) Lafayette School Corporation Health Services Diabetes Management and Treatment Plan for School (For the insulin pump student) Effective Dates: This plan should be complete by the student s personal health

More information

Anchor Bay School District Diabetic Medical Care Plan. Student Name Date Grade Teacher

Anchor Bay School District Diabetic Medical Care Plan. Student Name Date Grade Teacher Rev: 4/2009 Anchor Bay School District Diabetic Medical Care Plan Place Child s Picture Here Student Name Date Grade Teacher Emergency Contact information (Please list in order to be called) #1 Parent

More information

P.S. Please remember to bring your completed forms to your office visit!

P.S. Please remember to bring your completed forms to your office visit! Dear Patient: Please print the following forms and complete them as accurately as possible and bring them with you to your office visit. If you have any questions about the forms you can call my office

More information

Basal and Bolus Insulin 7/16/2014. Jackie Aday RN, BSN, CDE Jeni Neighbors RN, BSN, CDE. BASAL: Small amount of insulin infused every few minutes

Basal and Bolus Insulin 7/16/2014. Jackie Aday RN, BSN, CDE Jeni Neighbors RN, BSN, CDE. BASAL: Small amount of insulin infused every few minutes Jackie Aday RN, BSN, CDE Jeni Neighbors RN, BSN, CDE Insulin Pump Therapy Open looped system in which a small amount of insulin is continuously infused through a cannula or needle (basal rate) Larger doses

More information

DIABETES PACKET. To ensure your child s well-being, please provide the school with the following supplies:

DIABETES PACKET. To ensure your child s well-being, please provide the school with the following supplies: NSG-203A NORTH ROYALTON CITY SCHOOLS 6579 Royalton Road North Royalton, Ohio 44133 DIABETES PACKET Dear Parent/Guardian: You have indicated that your child has Diabetes. Please complete the attached SCHOOL

More information

The Nursing Department of Central CUSD 301 provides nursing services that promote students ability to learn. Our goals are to:

The Nursing Department of Central CUSD 301 provides nursing services that promote students ability to learn. Our goals are to: Date Dear (Parent / Guardian), The Nursing Department of Central CUSD 301 provides nursing services that promote students ability to learn. Our goals are to: o Assist students in learning how to take care

More information

Diabetes Insulin Pump Health Care Plan District Nurse Phone: 262-560-2104 District Nurse Fax: 262-560-2106

Diabetes Insulin Pump Health Care Plan District Nurse Phone: 262-560-2104 District Nurse Fax: 262-560-2106 EMPOW ERING A COMMUNITY OF LEARNERS AND LEADERS Diabetes Insulin Pump Health Care Plan District Nurse Phone: 262-560-2104 District Nurse Fax: 262-560-2106 Student DOB School Grade Doctor Phone School Year

More information

Last Name First Name MI. Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated

Last Name First Name MI. Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated Patient Information Last Name First Name MI Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated Race (circle): Black White Asian Other Ethnicity

More information

Insulin Dose Adjustment REAL-Time CGMS Guidelines for Subjects on Pump Therapy

Insulin Dose Adjustment REAL-Time CGMS Guidelines for Subjects on Pump Therapy Insulin Dose Adjustment REAL-Time CGMS Guidelines for Subjects on Pump Therapy In addition to using the blood sugar logs to adjust your insulin doses every week, you should also use your continuous glucose

More information

Diab.etes Me.dic.al-Ma-nage-me-n-t -P-la-n -.

Diab.etes Me.dic.al-Ma-nage-me-n-t -P-la-n -. Date of Plan: Diab.etes Me.dic.al-Ma-nage-me-n-t -P-la-n -. Effective Dates: WJ Student's Name: Date of Birth:,-..,,;... Date of Diabetes Diagnosis: Grade: Homeroom Teacher: Physical Condition: 0 Diabetes

More information

Equipment and Supplies Checklist for Parents Student: DOB: School: Grade: Equipment and Supplies to be Provided by Parent. Parent Signature Date

Equipment and Supplies Checklist for Parents Student: DOB: School: Grade: Equipment and Supplies to be Provided by Parent. Parent Signature Date Equipment and Supplies Checklist for Parents Student: DOB: School: Grade: Equipment and Supplies to be Provided by Parent Parent Signature Date Daily Snacks (for AM/PM snack times): Specify: Extra Snacks

More information

Diabetes Medical Management Plan

Diabetes Medical Management Plan Diabetes Medical Management Plan 1 School District: School: School Year: Grade: Student Name: DOB: Provider Name: Phone #: Fax #: Blood Glucose Monitoring at School Blood Glucose Target Range: - mg/dl

More information

Dear Parent/Guardian and Physician of

Dear Parent/Guardian and Physician of DIABETIC MANAGEMENT PLAN Parent Consent and Physician Authorization POWAY UNIFIED SCHOOL DISTRICT HEALTH SERVICES 15250 Avenue of Science San Diego CA 92128 Dear Parent/Guardian and Physician of California

More information

Your Road Map to Diabetes Medication Administration Record (Part 1)

Your Road Map to Diabetes Medication Administration Record (Part 1) Your Road Map to Diabetes Medication dministration Record (Part 1) Ohio Revised ode (3313.713) is the education law that addresses prescriptive medication administration in Ohio schools. This OR lists

More information

Basal Rate Testing Blood sugar is affected at any time by 1) basal insulin 2) food (carbohydrate) intake 3) bolus insulin (meal time and correction)

Basal Rate Testing Blood sugar is affected at any time by 1) basal insulin 2) food (carbohydrate) intake 3) bolus insulin (meal time and correction) Basal Rate Testing Blood sugar is affected at any time by 1) basal insulin 2) food (carbohydrate) intake 3) bolus insulin (meal time and correction) 4) activity and 5) other factors such as stress and

More information

SCHOOL DISTRICT #22 VERNON DIABETES POLICY

SCHOOL DISTRICT #22 VERNON DIABETES POLICY SCHOOL DISTRICT #22 VERNON DIABETES POLICY A student with diabetes does not automatically qualify for additional support. The student may qualify as a temporary D category (chronic health) after diagnosis

More information

Patient Registration Form

Patient Registration Form 900 Carillon Parkway Suite 404 St. Petersburg, FL 33716 727-572-1333 727-572-1331 fax www.spencerdermatology.com Patient Registration Form Today s : Name: Suffix First Middle Last of Birth: / / Age: Sex:

More information

Calculating Insulin Dose

Calculating Insulin Dose Calculating Insulin Dose First, some basic things to know about insulin: Approximately 40-50% of the total daily insulin dose is to replace insulin overnight, when you are fasting and between meals. This

More information

Stonebridge Adult Medicine, P.A. Registration Form (Please Print)

Stonebridge Adult Medicine, P.A. Registration Form (Please Print) Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female

More information

I have diabetes. In case of emergency, please call: Healthcare Provider s Name. Name. Telephone. Address. Hospital. City. Pharmacy.

I have diabetes. In case of emergency, please call: Healthcare Provider s Name. Name. Telephone. Address. Hospital. City. Pharmacy. Self-Care Diary Name Address City Healthcare Provider s Name Hospital State ZIP I have diabetes. In case of emergency, please call: Name Pharmacy Diabetes Educator s Name Address 1 Small Steps to Managing

More information

Insulin Pump Management and Continuous Glucose Monitoring Systems (CGMS)

Insulin Pump Management and Continuous Glucose Monitoring Systems (CGMS) Insulin Pump Management and Continuous Glucose Monitoring Systems (CGMS) Faith Daily, RN, BSN, CDE, CPT Certified Diabetes Educator/Insulin Pump Trainer August 16, 2014 Why Pump Therapy? Mimics normal

More information

The Diabetes Self Management Insulin Pump Therapy Program

The Diabetes Self Management Insulin Pump Therapy Program The Diabetes Self Management Insulin Pump Therapy Program Is part of a Nationally recognized program taught by CPT s Offers classes during the daytime in a three part series: PRE-PUMP CLASS SALINE START

More information

Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470

Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470 PLEASE FILL OUT THIS SHEET COMPLETELY AND CORRECTLY. PLEASE PROVIDE ALL INSURANCE CARDS TO THE RECEPTIONIST TO COPY. Name Social Security # Address City, State & Zip Code Home Phone No. ( ) Cell Phone

More information

11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509

11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509 PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED

More information

Name Date. Doctor. Usual times to test glucose at school Extra tests (check those that apply) before exercise after exercise other (explain)

Name Date. Doctor. Usual times to test glucose at school Extra tests (check those that apply) before exercise after exercise other (explain) Appendix A SAMPLE IHP Name Date Phone numbers Blood glucose Hypoglycemia Hyperglycemia Insulin Parent/guardian#1 Work Home Parent/guardian#2 Work Home Other emergency contact Doctor Usual times to test

More information

MISSION STATEMENT. Simple, straight talk for complicated medical issues

MISSION STATEMENT. Simple, straight talk for complicated medical issues I have known since ninth grade in high school that I wanted to be a physician, specifically, an endocrinologist. To accomplish this I graduated from high school second out of 450 and then attended the

More information

Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?

Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice? Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013 Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone:

More information

Medicare Health Risk Assessment Questionnaire

Medicare Health Risk Assessment Questionnaire Medicare Health Risk Assessment Questionnaire Instructions: Please complete and return it in the self-addressed stamped envelope provided. If you have questions or need help completing the questionnaire,

More information

after meals Monitoring: Control your the Power to bedtime before meals ActiveCare Basics ActiveCare Basics

after meals Monitoring: Control your the Power to bedtime before meals ActiveCare Basics ActiveCare Basics ActiveCare Basics This pamphlet is an educational resource published for participants in the Diabetes ActiveCare Program through Prescription Solutions. To order your diabetes testing supplies, call toll-free

More information

Diabetes. Emergency Checklists. From A Child in Your Care Has Diabetes. A Collection of Information. Copyright 2005 by Elisa Hendel, M.Ed.

Diabetes. Emergency Checklists. From A Child in Your Care Has Diabetes. A Collection of Information. Copyright 2005 by Elisa Hendel, M.Ed. Diabetes Emergency Checklists From A Child in Your Care Has Diabetes. A Collection of Information. Copyright 2005 by Elisa Hendel, M.Ed. Hyperglycemia High Blood Sugar * Hyperglycemia occurs when the blood

More information

**Medicare and Medicaid have other Billing Codes and different eligibility. Please contact our office for more information. Thank you!

**Medicare and Medicaid have other Billing Codes and different eligibility. Please contact our office for more information. Thank you! Checking Your Insurance Benefits IMPORTANT Please check your insurance coverage prior to any Nutrition or Diabetes Education appointment. You will be responsible for any services that are not covered.

More information

Patient s Last Name First MI. Social Security # Date of Birth. Age Sex M F Family Referring Doctor Doctor. Home Address Apt # City State Zip

Patient s Last Name First MI. Social Security # Date of Birth. Age Sex M F Family Referring Doctor Doctor. Home Address Apt # City State Zip Klein & Associates, M.D., P.A. Registration Form Patient s Last Name First MI Social Security # Date of Birth Age Sex M F Family Referring Doctor Doctor Home Address Apt # City State Zip Home Phone ( )

More information

METROPOLITAN EYE CARE Scott B. Pomerantz, M.D., Thomas J, LoPresti, O.D. 523 Forest Avenue Paramus, NJ 07652 (201) 262-5070

METROPOLITAN EYE CARE Scott B. Pomerantz, M.D., Thomas J, LoPresti, O.D. 523 Forest Avenue Paramus, NJ 07652 (201) 262-5070 METROPOLITAN EYE CARE Scott B. Pomerantz, M.D., Thomas J, LoPresti, O.D. 523 Forest Avenue Paramus, NJ 07652 (201) 262-5070 Please complete and sign where indicated Patient Information: Last Name: First

More information

My Sick Day Plan for Type 1 Diabetes on an Insulin Pump

My Sick Day Plan for Type 1 Diabetes on an Insulin Pump My Sick Day Plan for Type 1 Diabetes on an Insulin Pump When you are sick, your blood sugar levels may be harder to keep under control. Your blood sugar may go too high or too low. Use this guide to help

More information

MVA Accident Questionnaire

MVA Accident Questionnaire MVA Accident Questionnaire Name Date Date of Accident Time of Accident Road conditions at time of accident Were you the driver? Were you the passenger? Where were you seated in the vehicle? FRONT BACK

More information

Patient History Information

Patient History Information Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:

More information

An Overview of Medicare Covered Diabetes Supplies and Services

An Overview of Medicare Covered Diabetes Supplies and Services News Flash - Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers serves as a resource on how to read and understand a Remittance Advice (RA). Inside

More information

My Doctor Says I Need to Take Diabetes Pills and Insulin... What Do I Do Now? BD Getting Started. Combination Therapy

My Doctor Says I Need to Take Diabetes Pills and Insulin... What Do I Do Now? BD Getting Started. Combination Therapy My Doctor Says I Need to Take Diabetes Pills and Insulin... What Do I Do Now? BD Getting Started Combination Therapy How Can Combination Therapy Help My Type 2 Diabetes? When you have type 2 diabetes,

More information

Young Marines Diabetes Care Plan

Young Marines Diabetes Care Plan PO Box 70735, SW Station Washington, DC 20024-0735 800-717-0060 office / 202-889-0502 fax Young Marines Diabetes Care Plan Child s Name: Date of Birth: Age: Unit: Event: (Drill, Encampment, SPACES, NDSP,

More information

SAMPLE SECTION 504 PLAN

SAMPLE SECTION 504 PLAN SAMPLE SECTION 504 PLAN The attached sample Section 504 Plan was developed by the American Diabetes Association (ADA) and the Disability Rights Education and Defense Fund, Inc. (DREDF). 0 MODEL 504 PLAN

More information

Introduction. We hope this guide will aide you and your staff in creating a safe and supportive environment for your students challenged by diabetes.

Introduction. We hope this guide will aide you and your staff in creating a safe and supportive environment for your students challenged by diabetes. Introduction Diabetes is a chronic disease that affects the body s ability to metabolize food. The body converts much of the food we eat into glucose, the body s main source of energy. Glucose is carried

More information

Is what you know about INSULIN PUMP THERAPY. This educational resource is provided by Medtronic MiniMed, Inc.

Is what you know about INSULIN PUMP THERAPY. This educational resource is provided by Medtronic MiniMed, Inc. Is what you know about INSULIN PUMP THERAPY MYTH or? This educational resource is provided by Medtronic MiniMed, Inc. You have to know a lot about technology to learn to use a pump Interacting with your

More information

(928) 854-4307 MEDICAL HISTORY. Weight: _ Shoe size: _

(928) 854-4307 MEDICAL HISTORY. Weight: _ Shoe size: _ 2302 N. Stockton Hill Rd Ste. G 1731 Mesquite Ave Ste 4 1200 Mohave Rd MEDICAL HISTORY Weight: Shoe size: ~~~~~~~~~~~~~~~~~~~~~~~~~~PLEASECIRCLE: RIGHT or LE~ Is your problem due to an accident? YES or

More information

4/7/2015 CONFLICT OF INTEREST DISCLOSURE OBJECTIVES. Conflicts of Interest None Heather Rush. Heather M. Rush, APRN, CDE Louisville, KY

4/7/2015 CONFLICT OF INTEREST DISCLOSURE OBJECTIVES. Conflicts of Interest None Heather Rush. Heather M. Rush, APRN, CDE Louisville, KY Heather M. Rush, APRN, CDE Louisville, KY CONFLICT OF INTEREST DISCLOSURE Conflicts of Interest None Heather Rush A conflict of interest exists when an individual is in a position to profit directly or

More information

Resident s Guide to Inpatient Diabetes

Resident s Guide to Inpatient Diabetes Resident s Guide to Inpatient Diabetes 1. All patients with diabetes of ANY TYPE, regardless of reason for admission, must have a Hemoglobin A1C documented in the medical record within 24 hours of admission

More information

type 2 diabetes and you Live Well with Diabetes

type 2 diabetes and you Live Well with Diabetes type 2 diabetes and you Live Well with Diabetes Basic Guidelines for Good Diabetes Care Check your blood sugar regularly At every doctor visit: Review your blood sugar records Blood pressure Weight Foot

More information

The Basics of Insulin Pump Therapy

The Basics of Insulin Pump Therapy The Basics of Insulin Pump Therapy Table of Contents The Basics of Insulin Pump Therapy Introduction Welcome... 3 Chapter 1 Balancing Glucose and Insulin............................. 10 Section 1: Glucose,

More information

A pictorial guide to diabetes care, supplies, and devices

A pictorial guide to diabetes care, supplies, and devices A pictorial guide to diabetes care, supplies, and devices Caution: This publication contains depictions of blood, needles and medical procedures related to diabetes care. This publication may be reproduced

More information

Blood Glucose Management

Blood Glucose Management Blood Glucose Management What Influences Blood Sugar Levels? There are three main things that influence your blood sugar: Nutrition Exercise Medication What Influences Blood Sugar Levels? NUTRITION 4 Meal

More information

Insulin Pump Therapy

Insulin Pump Therapy CHILDREN S SERVICES Insulin Pump Therapy These guidelines are not intended for starting a patient on an insulin pump. They are intended to give staff not part of the diabetic team information regarding

More information

FAMILY PRACTICE PATIENT REGISTRATION FORM

FAMILY PRACTICE PATIENT REGISTRATION FORM FAMILY PRACTICE PATIENT REGISTRATION FORM **Today s Date: Clinic Name: Healthy Texan Pediatrics and Family Medicine PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: _ *First

More information

Faculty Group Practice Patient Demographic Form

Faculty Group Practice Patient Demographic Form Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Patient Information Street Address City State Zip Home Phone SSN of Birth Gender Male Female Work Phone Cell Phone Marital

More information

A Simplified Approach to Initiating Insulin. 4. Not meeting glycemic goals with oral hypoglycemic agents or

A Simplified Approach to Initiating Insulin. 4. Not meeting glycemic goals with oral hypoglycemic agents or A Simplified Approach to Initiating Insulin When to Start Insulin: 1. Fasting plasma glucose (FPG) levels >250 mg/dl or 2. Glycated hemoglobin (A1C) >10% or 3. Random plasma glucose consistently >300 mg/dl

More information

Type 1 Diabetes Management Based on Glucose Intake www.utmem.edu/endocrinology click Patients (Revised 7/13/2007)

Type 1 Diabetes Management Based on Glucose Intake www.utmem.edu/endocrinology click Patients (Revised 7/13/2007) Type 1 Diabetes Management Based on Glucose Intake www.utmem.edu/endocrinology click Patients (Revised 7/13/2007) The following is a system of insulin therapy, diet management, and blood glucose monitoring

More information

WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called?

WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called? Today s Date: / / WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT Full Name: What would you prefer to be called? Street Address (If P. O. Box, provide street address

More information

Diabetes Mellitus: Type 1

Diabetes Mellitus: Type 1 Diabetes Mellitus: Type 1 What is type 1 diabetes mellitus? Type 1 diabetes is a disorder that happens when your body produces little or no insulin. The lack of insulin causes the level of sugar in your

More information

Taking Insulin Pumps to School. Rachel Calendo, MS, RN, CPNP, CDE, Martha Cuevas, RN, BSN, CPT

Taking Insulin Pumps to School. Rachel Calendo, MS, RN, CPNP, CDE, Martha Cuevas, RN, BSN, CPT Taking Insulin Pumps to School Rachel Calendo, MS, RN, CPNP, CDE, Martha Cuevas, RN, BSN, CPT Insulin Pumps Today A micro-computer, about the size of a pager Programmed to deliver both a preset amount

More information

BLOOD GLUCOSE MONITORING MEDICATION

BLOOD GLUCOSE MONITORING MEDICATION DIABETES CARE FOR SCHOOL MEDICAL MANAGEMENT PLAN Most Recent A1C and Date: BLOOD GLUCOSE MONITORING Meter Type: Testing Independently: yes no Testing times: Before meals Two hours after insulin dosing

More information

Chapter 1 The Importance of Education in Diabetes

Chapter 1 The Importance of Education in Diabetes Chapter 1 The Importance of Education in Diabetes H. Peter Chase, MD DeAnn Johnson, RN, BSN, CDE INTRODUCTION Families and children need to understand as much as possible about diabetes. A shorter book,

More information

New York Ophthalmology, P.C.

New York Ophthalmology, P.C. New York Ophthalmology, P.C. Dear Patient, Ophthalmology * PLEASE PRINT ON SINGLE SIDED, WHITE PAPER * Opthalmic Surgery Optometry * PLEASE USE BLACK INK ON ALL FORMS * Cornea External Disease Laser Vision

More information

Section 504 Plan (pg 1 of 8)

Section 504 Plan (pg 1 of 8) Section 504 Plan (pg 1 of 8) of Birth School Today s Section 504 Plan for: Disability: Diabetes School Year: Grade: Homeroom Teacher: Bus Number: Background Objectives The student has type diabetes. Diabetes

More information

Linda S. Caley, MS, RD Nutrition Counseling P.O. Box 811 Colchester, CT 06415 860-204-2691 fax: 860-537-1768. Last Name First Name Middle Initial

Linda S. Caley, MS, RD Nutrition Counseling P.O. Box 811 Colchester, CT 06415 860-204-2691 fax: 860-537-1768. Last Name First Name Middle Initial Linda S. Caley, MS, RD Nutrition Counseling P.O. Box 811 Colchester, CT 06415 860-204-2691 fax: 860-537-1768 CLIENT REGISTRATION INFORMATION (Please Print) Last Name First Name Middle Initial Street Address

More information

Feeling sick? What to do. Information for people with Type 1 Diabetes

Feeling sick? What to do. Information for people with Type 1 Diabetes Feeling sick? What to do Information for people with Type 1 Diabetes Diabetes and sick days A minor illness can result in a major rise in blood glucose levels Common illnesses such as tonsillitis, ear,

More information

Chapter 21 Adjusting the Insulin Dosage and Thinking Scales

Chapter 21 Adjusting the Insulin Dosage and Thinking Scales Chapter 21 Adjusting the Insulin Dosage and Thinking Scales BLOOD SUGAR GOALS (suggested ranges) It is our general goal to have blood sugar levels in the ranges listed below (also see Chapter 7). These

More information

Medical Assistant s Diabetes Survey

Medical Assistant s Diabetes Survey Medical Assistant s Diabetes Survey Instructions: Circle one answer for each question. Thank-you. Basic Knowledge 1. Risk factors for developing Type 2 diabetes include: a. Family members with diabetes

More information

Student Name: Date of Birth:

Student Name: Date of Birth: Place Photo Here ITASCA DISTRICT 10 DIABETES CARE PLAN Student Name: Date of Birth: Date of Conference: School Nurse: Health Data: has diabetes. This is a condition in which the pancreas is unable to make

More information

*WELCOME TO OUR OFFICE*

*WELCOME TO OUR OFFICE* *WELCOME TO OUR OFFICE* WE FIND THAT COMMUNICATION WITH OUR PATIENTS REGARDING OUR BUISNESS OFFICE POLICIES ASSISTS US IN PROVIDING YOU THE BEST SERVICE. THEREFORE WE HAVE PROVIDED A HIGHLIGHT OF SOME

More information

Riley Hospital for Children General Diabetes Medical Management Information- Injections

Riley Hospital for Children General Diabetes Medical Management Information- Injections Riley Hospital for Children General Diabetes Medical Management Information- Injections 1. HEALTH CARE SUPERVISION All school support staff, including: secretaries, cafeteria staff, custodians and bus

More information

A guidebook for people with diabetes

A guidebook for people with diabetes A guidebook for people with diabetes This booklet is designed to supplement, not replace, your doctor s advice. Please consult your doctor if you have any questions about what you read. You ll learn how

More information

THE INS AND OUTS OF INSULIN. Mary Beth Wald, RN,BSN,CDE

THE INS AND OUTS OF INSULIN. Mary Beth Wald, RN,BSN,CDE THE INS AND OUTS OF INSULIN Mary Beth Wald, RN,BSN,CDE WHAT HAPPENS IN MY BODY? When we eat, the food gets changed into glucose, a type of sugar. Glucose travels in the blood to all the cells in your body

More information

Diabetes Medications: Insulin Therapy

Diabetes Medications: Insulin Therapy Diabetes Medications: Insulin Therapy Courtesy Univ Texas San Antonio Eric L. Johnson, M.D. Department of Family and Community Medicine Diabetes and Insulin Type 1 Diabetes Autoimmune destruction of beta

More information

Insulin Initiation and Intensification

Insulin Initiation and Intensification Insulin Initiation and Intensification ANDREW S. RHINEHART, MD, FACP, CDE MEDICAL DIRECTOR AND DIABETOLOGIST JOHNSTON MEMORIAL DIABETES CARE CENTER Objectives Understand the pharmacodynamics and pharmacokinetics

More information

Diabetes Fundamentals

Diabetes Fundamentals Diabetes Fundamentals Prevalence of Diabetes in the U.S. Undiagnosed 10.7% of all people 20+ 23.1% of all people 60+ (12.2 million) Slide provided by Roche Diagnostics Sources: ADA, WHO statistics Prevalence

More information

PATIENT INFORMATION. Patient: S.S.# Address: D.O.B. Home Phone: Bus Phone: Male Female. Emergency contact: Relation to Patient: PH#

PATIENT INFORMATION. Patient: S.S.# Address: D.O.B. Home Phone: Bus Phone: Male Female. Emergency contact: Relation to Patient: PH# Massage 258 West 91 st Street, Suite 1-B Physical THERAPY EXPERTS, PLLC WELCOME 212-875-8345 T PLEASE FILL IN FORM COMPLETELY TO AVOID INSURANCE PAYMENT DELAY! PATIENT INFORMATION Patient: S.S.# Address:

More information

Type 1 Diabetes. Dr. Tom Elliott MBBS, FRCPC Medical Director

Type 1 Diabetes. Dr. Tom Elliott MBBS, FRCPC Medical Director Dr. Tom Elliott MBBS, FRCPC Medical Director 4102 2775 Laurel St. phone: 604.675.2491 Vancouver, BC fax: 604.875.5931 V5Z 1M9 Canada email: info@bcdiabetes.ca Type 1 Diabetes Type 1 diabetes was previously

More information

Welcome to Tri-State Rehab Services

Welcome to Tri-State Rehab Services Welcome to Tri-State Rehab Services Ashland Ironton Jackson Louisa New Boston Westmoreland Thank you for choosing our facility. To help us meet all your physical therapy needs, please fill out forms completely

More information

Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:

Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other: At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We

More information

THE EYE INSTITUTE. Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0465

THE EYE INSTITUTE. Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0465 THE EYE INSTITUTE Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0465 Dear Patient: Welcome to the Eye Institute. Our mission is to provide you with the highest

More information

Lake Oswego Eye Clinic 530 First ST, Suite A Lake Oswego, OR 97068 Office: (503) 636-9608 Fax: (503) 636-9600

Lake Oswego Eye Clinic 530 First ST, Suite A Lake Oswego, OR 97068 Office: (503) 636-9608 Fax: (503) 636-9600 PAYMENT AGREEMENT: We accept most insurance plans as a courtesy. We encourage you to familiarize yourself with your individual plan. Insurance coverage is an agreement between patient and insurance company

More information

OFFICE POLICIES. Please note that NO controlled substance requests can be filled via phone as per DEA regulations. (initial)

OFFICE POLICIES. Please note that NO controlled substance requests can be filled via phone as per DEA regulations. (initial) OFFICE POLICIES Thank you for choosing Spencer Dermatology and Skin Surgery Center for your health care needs. We recognize that you have a choice in health care providers and we appreciate the trust that

More information

Diabetes Education Information for Teachers and School staff

Diabetes Education Information for Teachers and School staff Diabetes Education Information for Teachers and School staff The information below is intended to educate school staff on the basics of diabetes care. If you have a student in your classroom or you will

More information

A Reference Guide for School Nurses. with the Medtronic MiniMed Insulin Pump

A Reference Guide for School Nurses. with the Medtronic MiniMed Insulin Pump A Reference Guide for School Nurses with the Medtronic MiniMed Insulin Pump Table Of Contents I Table of Contents The Medtronic MiniMed Insulin Pump A Reference Guide for School Nurses For the 522, 722,

More information

ISLET TRANSPLANT APPLICATION FORM

ISLET TRANSPLANT APPLICATION FORM 5/2014 Page 1 of 17 ISLET TRANSPLANT APPLICATION FORM INSTRUCTIONS: This application and the information you provide will be used to determine if you are able to participate in an islet transplant trial

More information

Objectives PERINATAL INSULIN PUMPS: BASICS FOR NURSES. Historical Perspective. Insulin Pumps in Pregnancy. Insulin Pumps in the US

Objectives PERINATAL INSULIN PUMPS: BASICS FOR NURSES. Historical Perspective. Insulin Pumps in Pregnancy. Insulin Pumps in the US Objectives PERINATAL INSULIN PUMPS: BASICS FOR NURSES Jo M. Kendrick, APN BC, CDE jkendric@utmck.edu Describe indications and contraindications for insulin pump use in hospitalized patients Differentiate

More information

Insulin/Diabetes Calculations

Insulin/Diabetes Calculations Insulin/Diabetes Calculations Dr. Aipoalani St Lukes Endocrinology Goals Describe various calculations for insulin dosing Understand importance of the total daily dose (TDD) of insulin Be able to calculate

More information

THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:

THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: Social Security Number: Employment Status: Marital Status: Emp Unemp

More information

! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002

! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002 ! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002 PATIENT INFORMATION PATIENT NAME (Last, First, Middle Initial) DATE OF BIRTH AGE ADDRESS SOCIAL SECURITY NUMBER CITY, STATE, ZIP Male GENDER

More information

PEBTF s Get Healthy Program Know Your Numbers Wellness Screenings Frequently Asked Questions

PEBTF s Get Healthy Program Know Your Numbers Wellness Screenings Frequently Asked Questions PEBTF s Get Healthy Program Know Your Numbers Wellness Screenings Frequently Asked Questions The Pennsylvania Employees Benefit Trust Fund (PEBTF) is pleased to offer the third annual Get Healthy Program

More information

Managing Diabetes in the Athletic Population

Managing Diabetes in the Athletic Population Managing Diabetes in the Athletic Population Michael Prybicien, LA, ATC, CSCS, CES, PES Athletic Trainer, Passaic High School Overlook Medical Center & Adjunct Faculty, William Paterson University Dedicated

More information

THE EYE INSTITUTE. Dear Patient:

THE EYE INSTITUTE. Dear Patient: THE EYE INSTITUTE Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0464 Eye Institute North, LLC 5677 Berkshire Valley Rd. Oak Ridge, NJ 07438 p. 973-208-0600

More information