WhidbeyHealth – Patients first. Caring always.
-7905756031230D. Please send appropriate labsE. Please send Pertinent MedicationsF. Ordering Provider (print) __________________________Signature ___________________Date:___________***Medicare requires MD cosign for DM and CKD referrals.***FAX completed form to: WHMC Centralized Scheduling FAX: 360-678-7652Questions or to schedule CALL: Scheduling Line phone number: 360-678-7607 Opt. #1 WhidbeyHealth Medical Center, 101 North Main Street Coupeville, WA 98239-0400 ATTN: Patient Access Scheduling00D. Please send appropriate labsE. Please send Pertinent MedicationsF. Ordering Provider (print) __________________________Signature ___________________Date:___________***Medicare requires MD cosign for DM and CKD referrals.***FAX completed form to: WHMC Centralized Scheduling FAX: 360-678-7652Questions or to schedule CALL: Scheduling Line phone number: 360-678-7607 Opt. #1 WhidbeyHealth Medical Center, 101 North Main Street Coupeville, WA 98239-0400 ATTN: Patient Access Scheduling27432001983105Lipid disorders E 78.0 Pure hypercholesterolemia E78.1 Pure hyperglyceridemia E78.2 Mixed hyperlipidemia E 88.81 Metabolic SyndromeWeight Management E66.3 Overweight E66.0 Obese d/t excess calories E66.01 Morbid obesity d/t excess calories E66.8 Other obesity E66.9 Obesity, unspecified R63.6 Underweight R63.4 Abnormal weight loss R63.5 Abnormal weight gainGastrointestinal K58 Irritable bowel syndrome K51 Ulcerative colitis K 90.0 Celiac diseaseOther: ICD-10 ________________________________Description: _________________________________00Lipid disorders E 78.0 Pure hypercholesterolemia E78.1 Pure hyperglyceridemia E78.2 Mixed hyperlipidemia E 88.81 Metabolic SyndromeWeight Management E66.3 Overweight E66.0 Obese d/t excess calories E66.01 Morbid obesity d/t excess calories E66.8 Other obesity E66.9 Obesity, unspecified R63.6 Underweight R63.4 Abnormal weight loss R63.5 Abnormal weight gainGastrointestinal K58 Irritable bowel syndrome K51 Ulcerative colitis K 90.0 Celiac diseaseOther: ICD-10 ________________________________Description: _________________________________-9144001983106C. Select all diagnoses that apply (All request must include a valid diagnosis) Diabetes?E10.9 Type 1 DM w/o complications?E11.9 Type 2 DM w/o complications?E 10.8 Type 1 DM with unspecified complications?E 11.8 Type 2 DM with unspecified complicationsOther: Fill in complete ICD-10 code?E10. ___ Type 1 DM w/______________________?E11. ___Type 2 DM w/_______________________?O24.410 Gestational DM, diet controlledEDC _____________________________________??R73.01 Impaired fasting glucoseChronic Kidney Disease N18.3 CKD Stage 3 N18.4 CKD Stage 4 N18.5 CKD.5Other: ICD-10 ________________________________Description: _________________________________00C. Select all diagnoses that apply (All request must include a valid diagnosis) Diabetes?E10.9 Type 1 DM w/o complications?E11.9 Type 2 DM w/o complications?E 10.8 Type 1 DM with unspecified complications?E 11.8 Type 2 DM with unspecified complicationsOther: Fill in complete ICD-10 code?E10. ___ Type 1 DM w/______________________?E11. ___Type 2 DM w/_______________________?O24.410 Gestational DM, diet controlledEDC _____________________________________??R73.01 Impaired fasting glucoseChronic Kidney Disease N18.3 CKD Stage 3 N18.4 CKD Stage 4 N18.5 CKD.5Other: ICD-10 ________________________________Description: _________________________________-8001001487805B. Referral for: ? Individual Nutrition Counseling/Medical Nutrition Therapy 00B. Referral for: ? Individual Nutrition Counseling/Medical Nutrition Therapy 1943100-685800Outpatient Medical Nutrition Therapy Referral Form(***Complete A, B, C, D, E, F for order)00Outpatient Medical Nutrition Therapy Referral Form(***Complete A, B, C, D, E, F for order)-685800-68580000-800100114300A. Patient Name: __________________________________________DOB:_________________________Address: ________________________________________City: ______________________State:_______Insurance: ______________________________________Phone: _________________________________Authorization Number: ___________________________________________________________________00A. Patient Name: __________________________________________DOB:_________________________Address: ________________________________________City: ______________________State:_______Insurance: ______________________________________Phone: _________________________________Authorization Number: ___________________________________________________________________ ................
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