Referral form to a diabetes prevention program

For a PDF version of this referral form, download here

    Patient Information


    By providing your information above, you authorize your health care practitioner to provide this information to a diabetes prevention program provider, who may in turn use this information to communicate with you regarding its diabetes prevention program.

    Practitioner Information (Completed by Health Care Practitioner)

    Screening Information

    Hemoglobin A1C

    Fasting Plasma Glucose

    2-hour plasma glucose (75 gm OGTT)

    For Medicare requirements, I will maintain this signed original document in the patient's medical record.

    By signing this form, I authorize my physician to disclose my diabetes screening results to the Bluegrass Lions Diabetes Project for the purpose of determining my eligibility for the diabetes prevention program and conducting other activities as permitted by law.

    I understand that I am not obligated to participate in this diabetes screening program and that this authorization is voluntary.

    I understand that I may revoke this authorization at any time by notifying my physician in writing. Any revocation will not have an effect on actions taken before my physician received my written revocation.

    IMPORTANT WARNING: The documents accompanying this transmission contain confidential health information protected from unauthorized use or disclosure except as permitted by law. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party unless permitted to do so by law or regulation. If you are not the intended recipient and have received this information in error, please notify the sender immediately for the return or destruction of these documents. Rev. 05/30/14

    * These BMI levels reflect eligibility for the National DPP as noted in the CDC Diabetes Prevention Recognition Program Standards and Operating Procedures. The American Diabetes Association (ADA) encourages screening for diabetes at a BMI of >= 23 for Asian Americans and >= 25 for non-Asian Americans, and some programs may use the ADA screening criteria for program eligibility. Please check with your diabetes prevention program provider for their specific BMI eligibility requirements.