Medicaid Reimbursement Application for Diabetes Education Programs

DIABETES EDUCATION PROGRAM

Application for Program Approval and Medicaid Reimbursement

Please print or type

Organization Name ______NPI #______

Mailing Address______

______

CityStateZip

Contact Person ______

Phone (_____)______FAX (_____)______

Email Address of contact person: ______@______

IMPORTANT: If your diabetes education program has Recognition from the American Diabetes Association, the American Association of Diabetes Educators, or Indian Health Service, submit only the first 2 pages of this application and a copy of the program’s Recognition Certificate or letter from ADA, AADE or IHS regarding Recognition.

Directions: Complete all sections of the application and return with all supporting documentation to:

Jeanne Harmon, RD, MBA, CDE

Department of Health

Diabetes Prevention and Control Program

PO Box 47855

Tumwater, WA 98501-7855

Phone (360)236-3750

Email:

You will be contacted if there are questions about your application. If your program is approved, you will receive written notification. Please allow 4 weeks for processing. Thank you for your interest in caring for people who have diabetes.

DIABETES EDUCATION PROGRAM

DOH Diabetes Prevention and Control Program

Page 2

Section I: Medical Advisor

What is the name, phone number and licensure of the Primary Health Care Provider who has responsibility for the oversight of your diabetes education program? Example: MD, PA-C, ARNP

How is this person affiliated with your organization?

Section IIReferral Process

Describe the referral process into your diabetes education program. Attach a referral form if you use one.

Section IIITeaching Team

Diabetes Education will be provided by one or more instructors. At least one of the instructors must be a registered nurse (RN), dietitian, (RD) or pharmacist (RPh or PharmD). Teaching team members who are currently Certified Diabetes Educators (CDE) need onlyattach documentation of their CDE status (no continuing education documentation needed). Teaching team members who are not CDE’s must attach documentation ofat least 6 hours of diabetes specific continuing education obtained within the last 2 years. Copy of current (unexpired) license, registration or certification is required for all teaching team members listed.

*Copy of currentlicense, registration, or certification required

**Documentation of continuing education hours required except for Certified Diabetes Educators

DIABETES EDUCATION PROGRAM

DOH Diabetes Prevention and Control Program

Page 3

Section IVCurriculum

Attach your curriculum in outline form with at least one educational objective for each of the seven topic areas listed below. (Please do not send in handouts).

* What is diabetes?

* Nutrition

* Exercise/Physical Activity

* Prevention of Acute Complications

* Prevention of Chronic Complications

* Monitoring

* Medications

Section VAssessment

Attach a client needs assessment form, which you use to determine what education is appropriate for each client.

The American Association of Diabetes Educators (AADE)’s practice documents inform and support the practice of diabetes education. Theyinclude official documents such as position statements, guidelines for practice, white papers, technical papers, and any other document that articulates the association'sviews and mission, reflects the current evidence and standards of diabetes care,supports the AADE7 Self-Care Behaviors framework, and provides technical guidance to practitioners. We recommend you use these documents in developing your diabetes education program.

Diabetes Education Program Resource List

The titles and contact organizations listed below can direct your efforts in exploring the vast field of diabetes education materials and your professional development. They are not intended to represent a complete review of the literature.

Professional and Program Development

Several publications are available from the American Association of Diabetes Educators (AADE) that will assist in developing your diabetes education program, or preparing yourself to take the Certification Examination for Diabetes Educators (CDE Exam). The AADE website is listed below under Key Resource Organizations.

The American Diabetes Association (ADA) and the American Association of Diabetes Educators (AADE) also provide resources for program development and for preparing an application for program recognition. Their websitesare listed below as well.

Key Resource Organizations

American Association of Diabetes Educators

100 W. Monroe, Suite 400

Chicago, IL 60603

1-800-338-3633

Website:

American Diabetes Association

1730 Minor Avenue Suite 920

SeattleWA 98101 1-800-DIABETES or (206)282-4616

Website:

National Diabetes Information Clearinghouse

PO Box NDIC

9000 Rockville Pike

Bethesda MD 20891(301)468-2162

Website:

For a list of additional resources for Health Professionals, visit the Washington State Diabetes Connection at

For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-525-0127 (TDD/TTY 1-800-833-6388).

Revised 10/2009