Rhode Island Diabetes and Cardiovascular Health Program Referral Form

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Required format:

Hello! The Rhode Island Diabetes and Cardiovascular Health Program is your go-to place for accessing evidence-based lifestyle change programs.

Please complete this referral form to begin the registration process and your journey to better health!

These programs are supported by the Diabetes and Cardiovascular Health Program 5-year CDC cooperative agreements NU58DP007414 and NU58DP007443.

Prediabetes Risk Test ID

Calendar Event ID

Program

Delivery Organization Name

Delivery Method

In-person

Hybrid (In-person and Virtual)

Virtual only

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Class Meeting Times

Address Line 1

Address Line 2

City

State

Zip

Delivery Location Address

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Program Start Date

M-D-Y

Language(s) Available

English

Spanish

Portuguese

Other

Prefilled Delivery Person Name

Prefilled Delivery Person Email

Prefilled Registration Data

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Referral Confirmation Number

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Program

* must provide value

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Who are you referring today?

* must provide value

Myself

A patient or client

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First Name

* must provide value

Last Name

* must provide value

Phone Number

* must provide value

Email (optional)

Preferred Language

* must provide value

English

Spanish

Other

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Preferred Time to Receive a Phone Call

* must provide value

No preference

Morning

Afternoon

Early Evening

Other

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How did you hear about ______? (Select all that apply)

Family or Friends

Primary Care Doctor or Nurse

Community Health Worker

Other Healthcare Professional

Community Based Organization

Department of Health Website

Social Media

Television

Radio

Podcast

Other

First Name

* must provide value

Last Name

* must provide value

Professional Title

* must provide value

Phone Number

* must provide value

Office Name

* must provide value

Organization Type

* must provide value

Healthcare Provider

Community-Based Organization

Other

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Are you a Community Health Worker (CHW)?

* must provide value

Yes

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Referral status updates are provided via email. If you would like to receive notifications letting you know the status of your referral (patient/client enrolled in the program, was added to a waitlist, declined to register, or could not be reached), please provide us with your organization's preferred email address. Email notifications are sent secure.

Re-type email address to confirm |

* must provide value

Having ______ participate in ______ comes with the option to receive Patient Enrollment, Progress, and Outcome Letters. These letters include information such as:

Notification of patient enrollment in the program
Progress updates with relevant biometrics
Notification of program completion and the patient's final health outcomes

Outcome letters are sent using fax.

Would you like to have Patient Enrollment, Progress, and Outcome Letters sent?

* must provide value

Yes

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Who should the letters be addressed to?

* must provide value

Fax Number for receiving letters

* must provide value

A Business Associate Agreement (BAA) between your organization-______-and the Rhode Island Department of Health is needed to authorize the sharing of outcome letters. If RIDOH does not have a BAA with your organization, we will call you at ______ to discuss establishing a BAA.

Referrers have acquired written consent from the patient to make a referral to RIDOH on their behalf, for RIDOH to share the patient's contact information with the delivery organization, and for the delivery organization to contact the patient. The disclosure of information is for the purpose of the patient being referred to a chronic disease education/self-management program.

Referrer Signature

* must provide value

Add signature

Additional Class Information

Calendar Event ID: ______

Delivery Organization: ______

Delivery Method: ______

Class Meeting Times: ______

Delivery Location Address:

______

Class Start Date: ______

Program Referring To
______

Referral Information
First Name: ______	Last Name: ______
Phone: ______	Email: ______
Preferred Language: ______	Preferred time to receive a phone call: ______

Your Information
First Name: ______	Last Name: ______	Phone: ______
Title/Occupation: ______	Organization Type: ______	Organization Name: ______
Signature: ______

Patient Enrollment, Progress, and Outcome Letter Recipient Information
Who should the letters be addressed to? ______
Fax number for receiving referrals: ______

Form Completion Date-Time

M-D-Y H:M

Mark field as:

[Clear value]

Refused to answer (REF)

Not applicable (NA)

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