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 Information

Please 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