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Phone:
(502) 234-1676
Host Event
Volunteer
Training Schedule
Sign Up Form
Event Calendar
Events Map
Blog
Resources
The PILL Podcast
Diabetes Prevention Programs
KY Health Departments
Take diabetes risk assessment
Referral form to a diabetes prevention program
Contact
About Us
DONATE
Referral form to a diabetes prevention program
For a PDF version of this referral form,
download here
Patient Information
First name
Address
Last name
Health Insurance
City
Gender
Male
Female
State
---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Birth date (mm/dd/yy)
ZIP code
Email
Phone
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)
Physician/NP/PA
Address
Practice Contact
City
Phone
State
---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Fax
ZIP code
Screening Information
Body Mass Index (BMI)
Eligibility = >= 24 (>= 22 if Asian)*
Blood test (check one)
Eligible Range
Test result (one only)
Hemoglobin A1C
5.7-6.4%
Fasting Plasma Glucose
100-125 mg/dL
2-hour plasma glucose (75 gm OGTT)
140-199 mg/dL
Date of Blood Test
For Medicare requirements, I will maintain this signed original document in the patient's medical record.
Date
Practitioner Signature
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.
Date
Patient Signature
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.