Diabetes Services Order Form

The fact: Diabetes self-management training (DSMT) and medical nutrition therapy (MNT) benefits are alarmingly underutilized by Medicare beneficiaries. 

Data from the Medicare Quality Improvement Organizations (QIOs) reveals the root causes of this under utilization are limited awareness/confusion of the benefits and how to order the benefits for a patient.

The response: AADE and ADA joined forces to develop the Diabetes Services Order Form, which is designed to be an easy and convenient way for a physician or a qualified non-physician practitioner to refer their Medicare patients with diabetes to a diabetes educator for DSMT and a registered dietitian for MNT.

The standardized referral form can be used by any facility or healthcare professional and includes the key referral information required to meet Medicare regulatory requirements for MNT and/or DSMT referrals, but the form itself is not required by Medicare.

Download the Diabetes Services Order Form:

The Diabetes Services Order Form is available in two different electronic versions to best fit the healthcare environment it will be used in.

Download the Adobe Acrobat ®(PDF) version


Physician educational resource:

AADE and ADA have also developed a backgrounder and education fact sheet that includes a summary of the Medicare MNT benefit requirements and DSMT requirements, as well as examples of how MNT and the DSMT services can be coordinated for qualifying Medicare beneficiaries.

Download the educational resource (PDF).

Questions or comments on the Diabetes Services Order Form can be sent to AADE's Content Development Department.