REFERRAL FOR MEDICAL NUTRITION THERAPY



PHYSICIAN REFERRAL for MEDICAL NUTRITION THERAPY

To: LINDA FARR, RDN, LD, FAND

NUTRITION ASSOCIATES OF SAN ANTONIO

4414 Centerview Drive, Suite 233 San Antonio, TX 78228

Phone: (210) 735-2402 Fax: (210) 735-1176 Website:

I am referring: _____________________________________________ ______________________

Patient’s Name—Please Print Patient DOB

Patient’s Age/Sex: __________ ___________________________ _______________________________ Daytime Phone Number Alternate Phone Number

PHYSICIAN’S ORDER:

_____ RD’s Discretion _____ MD’s Diet Prescription:__________________________________________________

_____ Other Instructions: ___________________________________________________________________________

MEDICAL NECESSITY--JUSTIFICATION FOR MNT:

PRIMARY REASON:

DIAGNOSIS ICD-10 CODE DIAGNOSIS ICD-10 CODE

_____CHF _________ _____Hepatitis—_______ _________

_____Celiac Disease _________ _____Hyperlipidemia _________

_____Cirrhosis of Liver _________ _____Hypertension _________

_____Crohn’s Disease _________ _____Hypoglycemia _________

_____Diabetes—Type 1 _________ _____IBS _________

_____Diabetes—Type 2 _________ _____Impaired Fasting Glucose _________

_____Diabetes—Gestational _________ _____NASH _________

_____Eating Disorder _________ _____Obesity _________

_____End Stage Liver Disease _________ _____Overweight _________

_____Fructose Malabsorption _________ _____Pancreatitis _________

_____GERD _________ _____Other: __________________________________

_____Gout _________

OTHER COMPLICATING MEDICAL CONDITIONS:

DIAGNOSIS ICD-10 CODE DIAGNOSIS ICD-10 CODE

_____Abnormal Weight Gain _________ _____Fibromyalgia _________

_____Abnormal Loss of Weight _________ _____Gastritis _________

_____Ascites _________ _____Gluten Intolerance _________

_____Anemia _________ _____Lactose Intolerance _________

_____Anorexia _________ _____Malnutrition _________

_____Barrett’s Esophagus _________ _____PCOS _________

_____Cachexia _________ _____Sleep Apnea _________

_____Digestive/Stomach Problems _________ _____Vitamin Deficiency_____ _________

_____Esophagitis _________ _____Other:___________________________________

_____Edema _________

PERTINENT LAB VALUES: PLEASE ATTACH SHEET

EXERCISE RECOMMENDATIONS:

______ Medical Clearance for Exercise

______ Exercise Limitations: _________________________________________________________

SPECIAL INSTRUCTIONS:

This medical nutrition therapy is a necessary part of the patient’s medical treatment for the diagnoses listed above.

__________________________________________ ____________________

Physician’s Signature Date

__________________________________________________

Please Print Physician Name

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download