Comience con el asesoramiento nutricional para la diabetes!

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La mayoría de los pacientes con seguro pagan 0 € de su bolsillo.

Estamos en red con la mayoría de los principales planes de seguros y aceptamos nuevos clientes. Nuestro objetivo es ponernos en contacto con tu paciente en un plazo de 24 horas laborables y concertar una cita en un plazo de 7 días, dependiendo de su horario y de la cobertura de su seguro. ¿Preguntas? No dudes en ponerte en contacto con nosotros en el 888-383-8520 (compatible con texto). También puedes enviarnos un fax al 844-572-0001 si te resulta más fácil.

Patient Information
Patient Name*
First NameLast Name
Patient Phone Number*
Patient Email*
Insurance (please note we only accept the insurances listed)*
State*
Patient Status*
Please note that Blue Shield only accepts the following preventive codes. Select any of these codes that apply to maximize your patient's benefits and reduce out-of-pocket costs.*
E88.819 Insulin resistanceE88.81 Metabolic syndromeE88.811 Insulin resistance syndrome, type AE88.819 Insulin resistance, unspecifiedE88.818 Other insulin resistanceE78.2 Mixed hyperlipidemiaE78.3 HyperchylomicronemiaE78.41 Elevated lipoproteinE78.49 Other hyperlipidemiaE78.5 Hyperlipidemia, unspecifiedE78.6 Lipoprotein deficiency
Please choose all diagnosis codes that apply*
Prediabetes: R73.03Impaired fasting glucose: R73.01Type 2 diabetes: E11.9Type 1 diabetes: E10.9Gestational diabetes mellitus in pregnancy: O24.419Cardiovascular: I25.10 (for coronary artery disease)Gastrointestinal disease unspecified: K52.9Chronic kidney disease unspecified: N18.9Essential hypertension: I10Hyperlipidemia (unspecified): E78.9Coronary artery disease: I25.10PCOS (Polycystic Ovary Syndrome): E28.2Anorexia nervosa: F50.0Bulimia nervosa: F50.2Binge eating disorder: F50.8Eating disorder unspecified: F50.9Abnormal weight loss: R63.4Abnormal weight gain - not during pregnancy: R63.5Underweight: E46"Obesity" (BMI of 30): E66.9"Overweight" (BMI of 25.0 to 29.9): E66.3Other
Is the Patient on insulin?*
Exercise/Activity Plan
Pertinent Medications
Lab Work (can also upload at bottom of form)
Hct/Hgb FBS Hgb A1c Total Chol HDL LDL Non HDL Trig Ua Micro Albumin/Cr BUN/Cr EGFR Na/K Phos/PTH Vit D
Values
Insurance Info
Patient Date of Birth (DOB)*
MonthDayYear
Date
Policy Group Number*
Member ID*
Phone Number on Back of Card*
Please enter a valid phone number.
Referring Provider
Referring Provider Name*
First NameLast Name
Referring Provider Clinic/Affiliation*
Referring Provider Specialty*
Referring Provider Phone*
Referring Provider Fax*
Referring Provider NPI*
Referring Provider Email*
Upload any relevant files (front & back of insurance card, labs, etc)
Cancelof
Please confirm that you have an ROI for us to reach out to this client.*
I have an ROII will get an ROI, but I have the client's permission for you to reach out to them
We do not service this state.
Unfortunately, we do not offer services in this state at this time. We'd still be happy to collect the patient's information in case we expand in the future.
What would you like to do?*
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¿Listo para recomendar?

La mayoría de los pacientes con seguro pagan 0 € de su bolsillo.

Patient Information

Insurance Info

Referring Provider

We do not service this state.