DIABETES SERVICES REFERRAL PROCESS
*For Patients 18 years of age and older
Electronic Referral
Register today to start submitting & tracking your referrals online
Faxed Referrals
• Download the common referral form
• Complete mandatory information on the referral form in order for the patient to be routed appropriately and in a timely manner
• Submit only completed referrals to Fax: 1-855-338-0442
Mandatory InformationPlease note that if any of the following items below are missing from the referral the Central Intake Program will be unable to process the referral & it will be sent back to the requesting practitioner for completion.
- Patient Information
Name, DOB, Address, Phone Number, Health card Number
- Diabetes Diagnosis
Clearly indicate the type of diabetes
ex: Type 1, Type 2, Pre-diabetes, Gestational Diabetes or Steroid-Induced
- Assessment Data
HbA1C & eGFR are required within the last 12 months
- Current Diabetes Medications
Complete list of current diabetes medications *If applicable
- Insulin Prescription Form
This form is only required when an insulin start is requested
- Requester Information
Please add the name, phone/fax, address, billing number
Diabetes Services Referral Form |
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