Dietician Service Referral Form

Dietician Service Referral Form
Section 1: Patient Information
First Name
Middle Name
Last Name
MMDDYYYY
Gender

FemaleMaleOther
Street Address
Street Address 2
City
State
ZIP Code
Phone Number
Email Address
example@example.com
Emergency Contact Name:
Relationship
Phone Number
Section 2: Insurance Information
Primary Insurance

Blue Cross Blue ShieldUnitedHealthcareAetnaCignaHumanaOther
Policy Number
Group Number
Insurance Phone Number
Subscriber Name
Subscriber Date of Birth

MonthDayYear
Date
Secondary Insurance (if applicable):
Insurance Company
Policy Number
Group Number
Insurance Phone Number
Subscriber Name
Subscriber Date of Birth

MonthDayYear
Date
Section 3: Physician/Healthcare Provider Information

Referring Physician/Healthcare Provider:
Name
NPI Number
Phone Number
Fax Number
Street Address
Street Address 2
City
State
ZIP Code
Section 4: Medical Justification
Diagnosis Information
Primary Diagnosis

DiabetesType 1Type 2Other Specified
Chronic Kidney Disease- Type

Stage 1Stage 2Stage 3aStage 3bStage 4Stage 5ESRDDialysis DependentWith HypertensionWith Congestive Heart FailureHyperglycemiaHypoglycemiaDiabetic Neuropathy UnspecifiedDiabetic MonocuropathyDiabetic Peripheral NeuropathyDiabetic GastroparcsisOther Specified Diabetic NeuropathyDiabetic Peripheral Vascular DiseaseWithout GangreneWith GangreneWith AmputationOther Circulatory ComplicatonsRetinopathyLeft EyeRight EyeBoth EyesDiabetic Cataract(s)HypertensionCongestive Heart Failure- TypeSystolicDiastolicBothAcuityAcuteChronicAcute on ChronicCardiomyopathy-TypeDilatedAlcoholic CardiomyopathyLipid DisordersHypercholesterolemiaFamilial HyperlipidemiaMixed HyperlipidemiaHyperlipidemiaDementia- SeverityMildModerateSeverDementia- TypeVascular DementiaMixedAlzheimer's DementiaOtherBipolar Disorder- TypeBipolar 1Bipolar 2DepressedManicType option 59With Psychotic FeaturesWithout Psychotic FeaturesMajor Depressive Disorder-TypeSingle EpisodeRecurrentChronic PainWeight Management- TypeObesity- UnspecifiedMorbid ObesityType option 69Hyper Ventilation SyndromeBariatric Surgery- TypeLap bandRoux en YSleeve GastrectomyComplications (if any)DysphagiaGERDLap-Band SlipPerforation of AnastomosisVitamin Deficiency
BMI
Explanation of Medical Necessity for Dietician Services:
Medical Necessity
Section 5: Service Information
Requested Service Start Date: MMDDYYYY
Requested Service End Date: MMDDYYYY
Special Diet Order

General WellnessDiabetic Friendly: Reduced Carbohydrate [about 45g per meal]Low CarbCardiac: Low Fat and SodiumLow SodiumCardiac: Low Fat and SodiumHeart FailureGluten FreeRenal DietVegetarian (Includes Dairy and Eggs)Special Request
Consistency

No RestrictionClear Liquid DietBariatric/Diabecytic Clear Liquid (sugar free)Bariatric/Diabetic Full Liquid (sugar free)Full LiquidPureeNectar ThickHoney ThickPudding ThickMechanical SoftBariatric Regular (no breads, pasta, rice, uncooked vegetables [nothing that is fibrous or will puff up]Regular
Intolerances
Food Allergies
Section 6: Consent and Authorization
I
(Patient Guardian Name), consent to the release of my medical information to the insurance company for the purpose of processing this referral and authorizing the meal delivery service.
Signature

Clear
Date

MonthDayYear
Date
Physician Healthcare Provider Authorization
(Physician/Healthcare Provider Name), certify that the above information is accurate, and that the meal delivery service is medically necessary for the patient's health condition.
Signature

Clear
Date

MonthDayYear
Date
Please attach a copy of the patient's insurance card(s) and Identification. Ensure all sections are completed to avoid processing delays.
Should be Empty: