kellyschoice referralform medical final2 bleed

1.4 MB·

Schedule a nutrition counseling appointment with
a Kelly’s Choice Registered Dietitian.
This service may be covered by your insurance as we
are a United Healthcare, Empire, Cigna, CDPHP, and
BCBS participating providers.
Services
• Education and expertise in:
- Type 2 Diabetes
- High Cholesterol
- High Blood Pressure
• In-person or telehealth nutrition counseling
Benefi ts
Whether you are looking to lose weight, manage a chronic disease, or want
to live your best life, Kelly’s Choice has scienced-based, proven programs
for everyone! Our team of registered dietitians can help increase energy and
workplace productivity, lower overall healthcare costs, aide in weight loss,
decrease brain fog, and so much more!
Get In Touch
office: [phone] | fax: [phone] | email: [email protected]
@Kellyschoice_nutrition
Kelly’s Choice, LLC
Kelly Springer MS, RDN, CDN
kellyschoice.org
SERVICES REFERRAL FORM
offi ce: [phone] | fax: [phone] | email: [email protected]
Patient Information
Full Name:
Address:
Date of Birth: Referring Physician:
Email: Phone:
Phone: Fax:
Work/Cell: Address:
Country: City/State:
RX
RD to assess and treat with nutrition therapy
Provide complete Diabetes Self Management Training
Instruct on nutrition therapy
PLEASE FAX THIS FORM AND PERTINENT LABS TO [phone]
CDM UNITS CPT CODES
97802TPV MNT Initial Assessment (15 min each) 97802
97803TPV MNT Reassessment (15 min each) 97803
97804TPV MNT Group (30 min each) 97804
Diagnosis Diagnosis Code Diagnosis Diagnosis Code
Diet Counseling & Surveillance Z71.3 Celiac Disease K90.0
Gestational Diabetes O24.410 Gastritis K29.7
Prediabetes R73.03 Gerd with/without Esophagiti K21.0/K21.9
Type 1 DM w/o complications E10.9 Constipation K59.00
Type 2 DM w/o complications E11.9 Diarrhea R19.7
Hypertension I10 Unspecifi ed Nutritional Defi ciency E63.9
Acute on Chronic CHF I50.23 Anorexia Nervosa (Unspecifi ed) F50.00
Hyperlipidemia/Dyslipidemia E78.5 Bulimia Nervosa F50.2
Hypercholesterolemia E78.0 Binge Eating Disorder F50.81
Metabolic Syndrome E88.81 Underweight R63.6
Chronic Kidney Disease, Unspecifi ed N18.9 Inappropriate Eating Habits Z72.4
Overweight E66.3 Anemia (Unspecifi ed) D64.9
Obesity/Morbid Obesity E66.8/E66.01 Lactose Intolerance E73.9
IBS (Other) K58.8 Bariatric Surgery Status Z98.84
Diverticulosis K57.9 HX of TIA or CVA Z86.73
Ulcerative Colitis K51.9
Crohn’s Disease K50.90
Diverticulitis K57.8 Thank you for choosing Kelly’s Choice!