Fillable diabetes or hyperglycemia on oral medications status report updated 08 30 2017-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name, birthdate, and applicant ID# in the designated fields at the top of the form.
3. Have your treating provider complete the section regarding their printed name and phone number, along with the date of your last clinical encounter for diabetes.
4. Fill in the date of your most recent diabetes medication change and provide your Hemoglobin A1C lab value along with its date. Ensure that this value is taken more than 30 days after any medication change.
5. List all current medications you are taking for any condition in the provided space. Be thorough to ensure accurate reporting.
6. Respond to questions about side effects, episodes of hypoglycemia, and any evidence of progressive diabetes-induced end organ disease by circling 'Yes' or 'No' as applicable.
7. If you circled 'Yes' on any question, attach relevant narratives or tests as instructed.
8. Finally, have your treating provider sign and date the form before submission.

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