NUTRITION SERVICES REFERRAL

Dietz Nutritional Consulting, LLC

The Forum, 625 Piney Forest Road, Suite 306D, Danville, VA 24540

Fax: (434) 791-3330 Phone: (434)548-0476 email:

PLEASE FAX COMPLETED REFERRAL AND GIVE A COPY TOTHE PATIENT
Patient’s Name:______
Address: ______
Phone:______Sex: M  F  DOB: ______
Insuranceplan: ______
ID#: ______Pre-auth. attached:  Yes  No
Referral Date:______Pt. allowed to exercise: Yes  No / ►PHYSICIANDATA(REQUIRED)
Name:______
Address:______
City:______State:______Zip:______
Phone: ______Fax:______
NPI:______Signature:______
►SERVICES TO BE PERFORMED ___Blood Glucose Monitoring Meter Instruction
___Initial Medical Nutrition Therapy (MNT) ___ Bariatric / Weight Loss Surgery MNT
___Follow-Up Medical Nutrition Therapy ___Weight Loss Program: Nutrition Behavior ChangewithExercise
___Initial Diabetes Self-Management Education Training ___Weight Loss Program: Nutrition Behavior Changewithout Exercise
___Follow-up Diabetes Self-Management Education & Training ___Supermarket Tours for Disease Management (label reading / shopping tips)
___Initial Pre-Diabetes Nutrition Education / MNT (*) ___Stress-Eating Coping / Training Skills
___Follow-up Pre-Diabetes Nutrition Education / MNT (*) ___OTHER: ______

►RX MEDICATIONS:Diabetes: ______Anti-Lipemic: ______

BP: ______Diuretic: ______Heart: ______

Other: ______

►LABS: A1c:______BG:______BG:______Chol:______LDL-C:______HDL-C:______Trig: ______BP: ______
Other:______
►DIAGNOSES (REASON FOR REFERRAL) CHECKALL THAT APPLY FOR REIMBURSEMENT AND MEDICAL NECESSITY
ICD-9 / BARIATRIC / ICD-9 / E N D O C R I N E
263.9 / LAGB post-op weight loss / 250.01 / Type 1 diabetes
783.1 / RYGB post-op abnormal weight gain / 250.03 / Type 1 diabetes, uncontrolled
579.30 / RYGB post-op non absorption / 250.00 / Type 2 diabetes
250.02 / Type 2 diabetes, uncontrolled
ICD-9 / C A R D I O V A S C U L A R / 648.83 / Gestational diabetes mellitus
401.1 / Hypertension, essential, benign / 251.2 / Hypoglycemia, nondiabetic
272.0 / Hypercholesterolemia / 790.21 / IFG (FPG ≥ 100 & < 126) (*)
272.1 / Hypertriglyceridemia / 790.2 / IGT (2h PG ≥ 140 & < 200) (*)
244.9 / Hypothyroidism, unspecified
ICD-9 / G A S T R O I N T E S T I N A L / 256.4 / PCOS
579.0 / Celiac / 277.7 / Syndrome X, dysmetabolic (*)
556.9 / Colitis, ulcerative, unspecified
564.0 / Constipation / ICD-9 / W E I G H T and O T H E R
555.9 / Crohn’s disease / 278.00 / Obesity, unspecified (BMI: 30-39.9)
562.10, 562.11 / Diverticulosis, diverticulitis / 278.01 / Obesity, morbid (BMI: ≥ 40)
531.8 / GERD / 278.02 / Overweight (BMI: 25-29.9)
564.1 / IBS / 307.1 / Anorexia Nervosa
271.3 / Lactose intolerance / 783.0 / Anorexia (loss of appetite)

OVER→

Dietz Nutritional Consulting, LLC IS CONVENIENTLYLOCATED AT:

The Forum

625 Piney Forest Road

Suite 306D

Danville, VA 24540

TO SCHEDULE AN APPOINTMENT:

Call(434) 548-0476

FOR PATIENT USE:

MY APPOINTMENT DATE IS:______AT:______(AM / PM)

PLEASE BRING THIS REFERRAL TO YOUR APPOINTMENT
*** 24-HOUR NOTICE REQUIRED IF UNABLE TO KEEP SCHEDULED APPOINTMENT ***

CHECKLIST OF ITEMS TO BE BROUGHT TO YOUR APPOINTMENT:

1) Medical insurance cards

2) List of all prescription medications and supplements (times taken and doses)

3) Copies of latest blood tests / labs(or have your physician fax to: (434) 791-3330)

4)This completed referral

5) Reading glasses, if needed

6) Blood glucose meter, if you have one(*)

7) Blood glucose log, if you have one (*)

(*) For patients being referred for diabetes management

MEDICAL OFFICE STAFF:

To obtain additional NutritionServicesReferralpads, CALL: Jennifer Dietz at (434) 548-0476