The document outlines the steps a primary care physician should take to enroll diabetes patients in a self-management education program run by MIHE. The physician completes a referral form with patient information and labs, faxes it to MIHE, who then contacts the patient to set up an assessment. After assessment, the patient is enrolled in the program. Physicians are notified upon completion or if a patient declines or cannot be reached.

1. How to Enroll Diabetes Patients
In the MIHE Diabetes Self-Management Program
(To be completed by the primary care physician)
1. DSME Referral Form: complete the Diabetes Self-Management Education Referral
Form with the patient’s information, the patient’s recent lab values, and the information
related to a need for self-management education. Please include your name, signature
and contact information at the bottom of the form.
2. Fax form and any relevant lab reports to MIHE at 248-475-4881.
3. MIHE will contact the patient to set up an initial assessment and patient will be asked to
contact their insurance company to verify coverage.
4. After the initial assessment the patient will then be enrolled into the program.
5. At the conclusion of the program, physicians will be notified of education provided.
6. Physicians will also be notified if the patient declines enrollment or is unreachable.
4986 Adams Rd., Suite E, Rochester, MI 48306 ▪ Toll free 866-648-3265 ▪ 248-475-4880 ▪ 248-475-4881 (fax)