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DIABETES SERVICES REFERRAL PROCESS

 

Electronic Referral

Register today to start submitting & tracking your referrals online

Faxed Referrals

• Download the common referral form
• Complete mandatory information of 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


Diabetes Services Referral Form