Medicare - Medical Referral Form
Referring MD, DO or medical Professional
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First Name
Last Name
NPI#
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Office Phone #
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FAX #
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Patient's Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Phone #
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Email
example@example.com
Primary Health Insurance
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MEDICARE Part B
Medicare Advantage plan
BCBS of GA
Anthem
UnitedHealth Care (UHC)
UHC - All Savers
UHC - Golden Rule
UMR
AETNA
Meritain Health
Nippon
CIGNA
MULTIPLAN
Other
Primary Subscriber ID#
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Secondary Health Insurance
Secondary Subscriber ID#
DIAGNOSIS coverd by Medicare
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O24.410-Diabetes, Gestational Diet-controlled
O24.414-Diabetes, Gestational Insulin-controlled
E10.-- - Type 1 Diabetes
N 18.1 - Chronic kidney disease, Stage 1
E10.64 - Type 1 Diabetes, with hypoglycemia
N 18.2 - Chronic kidney disease, Stage 2
E10.65 - Type 1 Diabetes, with hyperglycemia
N 18.3 - Chronic kidney disease, Stage 3
E11.2 - Type 2 Diabetes, with kidney compl.
N 18.4 - Chronic kidney disease, Stage 4
E11.5 - Type 2 Diabetes w/circulatory compl.
N 18.5 - Chronic kidney disease, Stage 5
E11.64 - Type 2 Diabetes w/hypoglycemia
Z 94.0 - Kidney transplant status
E11.65 - Type 2 Diabetes w/hyperglycemia
Other (add it below)
Other Diagnosis (Choose all that apply)
Z71.3 Dietary counseling and surveillance
E66.09 Obese due to excess of calories
E66.01 Obesity, morbid due to excess calories
E66.01 Drug induced Obesity
E66.3 Overweight
E66.8 Other obesity
R63.4 Abnormal weight loss
R63.5 Abnormal weight gain not during pregnancy
R63.6 Underweight
R63.3 Feeding Difficulties
D50.8 Other iron deficiency anemias (due to inadequate iron intake)
D50.9 Iron deficiency anemia, unspecified
D51.3 Other dietary vitamin B12 deficiency anemia (vegan anemia)
D51.9 Vitamin B12 deficiency
D52.0 Dietary folate anemia
D53.0 Protein deficiency anemia
D53.9 Nutrition anemia, unspecified (simple chronic anemia)
D64.9 Anemia, unspecified
E03.9 Hypothyroidism, unspecified
E05.90 Thyrotoxicosis, unspecified
E16.1 Other hypoglycemia
E16.2 Hypoglycemia, unspecified
E28.2 polycystic ovarian syndrome
E43.- Unspecified severe protein-calorie malnutrition
E44.0 Moderate protein-calorie malnutrition
E44.1 Mild protein-calorie malnutrition
E45 Retarded development following protein-calorie malnutrition
E46 Unspecified protein-calorie malnutrition
E64.0 Sequelae of protein-calorie malnutrition
E 55.9- Vitamin D deficiency
E73.0 - Congenital lactase deficiency
E73.1 - Secondary lactase deficiency
E73.8 Other lactose intolerance
E73.9 Lactose intolerance, unspecified
E 74.12- Hereditary Fructose Intolerance
E84 Cystic fibrosis
E 78.00 - Hypercholesterolemia, pure
E 78.1 Hypertriglyceridemia, pure
E 78.2 Hyperlipidemia, mixed
E78.3 Hyperchylomicronemia
E78.4 other Hyperlipidemia
E78.5 Hyperlipidemia, unsp.
E78.8 other disorders of lipoprotein metabolism
E78.9 Disorder of lipoprotein metabolism, unspecified
E 84.9 Cystic fibrosis, unsp
E88.81 Metabolic Syndrome
F44.5 Seizure disorders
F50.00 Anorexia Nervosa, unsp.
F50.01 Anorexia Nervosa, restricting type
F50.02 Anorexia nervosa, binge eating/purging type
F50.2 Bulimia Nervosa
F50.8 Other eating disorders (avoidant restrictive food intake, Pica, Dysorexia, etc)
F50.9 Eating disorders, unsp
G47.33 Obstructive sleep apnea (adult/pediatric)
J44.9 Chronic obstructive pulmonary disease (COPD) unsp.
I 11.0 Hypertensive heart disease with (congestive heart failure)
I 10 - Hypertension, essential
I12.-- Hypertensive chronic kidney disease
I50.9 Heart Failure, unsp
K21.0 GERD with esophagitis
K21.9 GERD without esophagitis
K21.7 Gastritis, unsp.
K22.719 Barrett's Esophagus w/dysplasia
K25.00 Gastric ulcer
K27.00 Peptic ulcer, site unsp.
k27.3 Peptic Ulcer without hemorrhage or perforation
K29.5 Gastritis chronic unsp.
K29.2 Alcoholic gastritis
K29.5 Unspecified chronic gastritis
K 50.00 Crohn's Disease of the small intestine without complications
K 50.10 Crohn’s Disease of large intestine
K50.8 Crohn Disease of both small and large intestine
K50.018 Crohn's disease of small intestine with other complication
K50.9 Crohn's disease, unsp.
K51.90 Colitis, ulcerative
K51.919 Colitis ulcerative, with unspecified complications
K57.1 Diverticulosis of small intestine without perforation or abscess
K57.3 Diverticulosis of large intestine without perforation or abscess
K58.1 irritable bowel syndrome with constipation
K58.0 irritable bowel syndrome with Diarrhea
K 59.0 Constipation
K 59.9 Constipation (functional intestinal disorder)
K59.1 Diarrhea, functional
K70.3 Alcoholic cirrhosis of Liver
K 71.9 Liver Disease, toxic unsp.
K75.81 non-alcoholic steatohepatitis
K76.00 Fatty liver no-alcoholic
K86.0 Alcoholic-induced chronic pancreatitis
K86.1 Other chronic pancreatitis
K 90.0 Celiac Disease
K90.41 non-celiac gluten sensitivity
N20.0 Calculus of kidney
M1A.3 Chronic gout due to renal impairment
M1A.9 Chronic gout, unspecified
M10.3 Gout due to renal impairment
M10.4 Other secondary gout
M10.9 Gout, unspecified
M81.0 Age-related osteoporosis without current pathological fracture
M81.8 Other osteoporosis without current pathological fracture
R73.01 Impaired fasting glucose
R73.02 Impaired glucose tolerance test (oral)
R73.03 Prediabetes
R73.09 other abnormal glucose tolerance test, pre-diabetes
R73.9 Hyperglycemia, unsp.
B20. - HIV
K52.2 Allergic and dietetic gastroenteritis and colitis
Z91.02 Food additives allergy status
Z91.010 Food allergy to peanuts
Z91.011 Food allergy to milk products
Z91.012 Food allergy to egg
Z91.013 Food allergy to seafood
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Additional Information
MD, DO, PAC - Signature
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