Health Care Practitioner Referral Form to theDiabetes PreventionProgram

Send competed forms to the Graves County Health Department Fax: (270) 247-0391 Email:

PATIENTINFORMATION
Firstname / Address
Last name / City
Healthinsurance / State
GenderMaleFemale / ZIPcode
Birth date(mm/dd/yy) / County
Email / Phone
Byprovidingyourinformationabove,youauthorizeyourhealthcarepractitionertoprovidethisinformationtoaDiabetesPreventionProgram provider,whomayinturnusethisinformationtocommunicatewithyouregardingitsDiabetesPreventionProgram.
PRACTITIONER INFORMATION (COMPLETED BY HEALTH CAREPRACTITIONER)
Physician/NP/PA / Address
Practicecontact / City
Phone / State
Fax / ZIPcode
SCREENINGINFORMATION
Body Mass Index(BMI) ______ / (Eligibility = ≥24* (≥22 ifAsian)
Blood test (checkone) / Eligiblerange / Test result (oneonly)
□Hemoglobin A1C / 5.7–6.4% / ______%
□FastingPlasma / Glucose / 100–125 mg/dL / ______mg/dl
□2-hour plasma glucose (75 gm OGTT) 140–199mg/dL / ______mg/dl
Date of blood test(mm/dd/yy):
For Medicarerequirements,Iwillmaintainthissignedoriginaldocumentinthepatient’smedicalrecord.
DatePractitionerSignature:
By signing this form, I authorize my physician to disclose my diabetes screening results to theGraves County Health Department for the purpose of determining my eligibility for theDiabetes Prevention Program and conducting other activities as permitted bylaw.
I understand that I am not obligated to participate in this diabetes screening program and thatthis authorization isvoluntary.
I understand that I may revoke this authorization at any time by notifying my physician inwriting.
Any revocation will not have an effect on actions taken before my physician received my writtenrevocation.
DatePatientSignature

IMPORTANT WARNING: The documents accompanying this transmission contain confidential health information protected from unauthorized use ordisclosure except as permitted by law. This information is intended only for the use of the individual or entity named above. The authorized recipient ofthis 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 intendedrecipient and have received this information in error, please notify the sender immediately for the return or destruction of these documents. Rev. 07/27/15

*SomediabetespreventionprogramprovidersrequireaBMIof≥25.Pleasecheckwithyourdiabetespreventionprogramproviderforeligibilityrequirements.

BMI calculationchart

WEIGHT
HEIGHT
5'0" / 67 / 69 / 71 / 72 / 74 / 76 / 78
5'1" / 64 / 66 / 68 / 70 / 72 / 74 / 76
5'2" / 62 / 64 / 66 / 68 / 70 / 72 / 73
5'3" / 60 / 62 / 64 / 66 / 67 / 69 / 71
5'4" / 59 / 60 / 62 / 64 / 65 / 67 / 69
5'5" / 57 / 58 / 60 / 62 / 63 / 65 / 67
5'6" / 55 / 57 / 58 / 60 / 62 / 63 / 65
5'7" / 53 / 55 / 57 / 58 / 60 / 61 / 63
5'8" / 52 / 53 / 55 / 56 / 58 / 59 / 61
5'9" / 50 / 52 / 53 / 55 / 56 / 58 / 59
5'10" / 49 / 50 / 52 / 53 / 55 / 56 / 58
5'11" / 48 / 49 / 50 / 52 / 53 / 55 / 56
6'0" / 46 / 48 / 49 / 50 / 52 / 53 / 54
6'1" / 45 / 46 / 48 / 49 / 50 / 52 / 53
6'2" / 44 / 45 / 46 / 48 / 49 / 50 / 51
6'3" / 43 / 44 / 45 / 46 / 48 / 49 / 50
6'4" / 41 / 43 / 44 / 45 / 46 / 48 / 49
6'5" / 40 / 42 / 43 / 44 / 45 / 46 / 48

Blue Underweight: Less than18.5Green HealthyWeight:18.5-24.9Yellow Overweight: 25 -29.9Orange Obese: 30 -39.9Red Extreme Obesity: 40 orgreater

BMIstandsfor“BODYMASSINDEX”whichisanestimateoftotalbodyfatbasedonheightandweight.Itisusedtoscreenforweightcategoriesthatmayleadtohealthproblems.

THEGOALformostpeopleistohaveaBMIinthegreenarea.ItisusuallybestforyourBMItostaythesameovertimeortograduallymovetowardthegreenarea.