Diabetes Education Program

Diabetes Education Referrals

Looking to refer patients to diabetes education?

Follow the instructions below to refer patients via CRISP or fax:

CRISP e-REFERRAL

Log-in to the Unified Landing Page at: ulp.crisphealth.org
Search the desired patient (First Name, Last Name, and Date of Birth are required).
Select the patient by clicking the box in the “Include” column on the right-hand side of the screen then access the “Referrals Web Form” by clicking the “Referrals” tab at the top of the screen.
Once in the “Referrals” tab, the Web Form will prepopulate with patient demographic information. Complete the following sections manually: Patient Vitals, Alternate Phone Number, and Email.
Select Nexus Montgomery Diabetes Program from the “Organization” dropdown.
Select either Diabetes Prevention Program or Diabetes Self-Management Training.
Note: The comment box is a required field provided for sharing pertinent patient notes.
Once the Web Form is complete, check the ‘Patient Consent” box then click “Submit” to send the referral.*

*A referral has only been successfully submitted if you receive a confirmation page and/or a confirmation email from CRISP.

Fax Referrals

Download the appropriate referral form below:

Diabetes Prevention Program (DPP) Referral Form
File Size:	316 kb
File Type:	pdf

Diabetes Self-Management Education & Support (DSMES) Referral Form
File Size:	369 kb
File Type:	pdf

Complete the form and indicate any required lab results and patient notes. Ensure that patient contact information is accurate and include referring provider or staff contact information.
Fax completed form to 301-881-0993. Nexus Montgomery staff will reach out if additional information is needed.

Nexus Montgomery staff will contact the patient within 48-72 hrs.

If you have any questions, please contact the Nexus Montgomery Diabetes Program :

NexusDiabetes@jssa.org
or
(301) 816-2632