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