Patient-Health Care Provider Contract

“Patients First” Patient-Health Care Provider Contract: This simple easy to use contract is the ultimate chat insert, one copy for the patient and one copy for the chart, Just pull it out at every visit and have the patient reread and initial it.

Patient-Health Care Provider Contract

I understand that if I agree to participate in the Intensive Diabetes Self-Management System, I will be expected to do the following:

1. Dedicate myself to getting my blood glucose level as close to normal as possible by following the instructions of the Diabetes Self-Management team.
2. Visit the clinic regularly for a physical examination, laboratory tests and nutrition counseling (follow-up visits will be scheduled every three months, or more frequently if deemed necessary by my Health Care Provider or other members of my health care team).
3. Bring a detailed, one-day food record to each follow-up visit, to provide necessary nutrition information for myself and my dietitian, and to adjust my eating habits to meet the nutrition goals established by my dietitian.
4. Use medication(s) as prescribed by my health care team.
5. Monitor my blood glucose levels at home as instructed, and bring the results to each follow-up visit.
6. Follow my prescribed exercise plan.
7. Obtain identification as a patient with diabetes in case of an emergency.
8. Ask my Health Care Provider and other members of my health care team to explain any aspect of my case that I do not entirely understand.
I understand that if I do not monitor myself carefully there is a risk of hypoglycemia.

I also understand that, if I do not strive to normalize my blood sugar, I am at increased risk of developing the complications of diabetes mellitus.

My signature indicates that I have read and understand the agreement.

____________________________________
Patient

____________________________________
Date

I agree to provide the leadership for the Intensive Diabetes Self-Management System. Team members will be available to answer your questions and help you self-manage your diabetes. I will continue to encourage you to maintain the best possible control of your diabetes.

____________________________________
Health Care Provider

____________________________________
Date

Patients First is a diabetes initiative of the American Association of Clinical Endocrinologists dedicated to enhancing the Standard of Care for the treatment of diabetes.

For more information, call 1-888-50 SUGAR.

AACE
1000 Riverside Avenue
Suite 205
Jacksonville, FL 32204

YOU
are the key to controlling your diabetes.

Patients who follow the Intensive Diabetes Self-Management System can, on average, delay major complications 15 years and add 5 years to their lives.