Hyperglycemia (High Blood Glucose)ADA - American Diabetes AssociDiabetesAmerican Dental AssociationH 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name and birthdate in the designated fields at the top of the form. This information is crucial for identification purposes.
3. Fill in your Applicant ID# and PI#. These identifiers help streamline processing.
4. Have your diabetes provider complete their section, including their printed name, phone number, and details about your last clinical encounter and medication changes.
5. Input your Hemoglobin A1C lab value along with the date it was taken. Ensure this value is from a test conducted within the specified timeframe.
6. List all current medications in the provided space. Be thorough to ensure accurate assessment.
7. Respond to questions regarding side effects, hypoglycemia episodes, and any evidence of progressive diabetes complications by circling 'Yes' or 'No'.
8. If applicable, provide additional narrative or tests as required for any 'Yes' responses.
9. Finally, have your treating provider sign and date the form before submission.

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