OUTPATIENT NUTRITION SERVICES
REFERRAL FORM

Please complete section 1 to refer a patient to Summa Health for Outpatient Nutrition Services. Please let the patient know we will contact them to schedule an appointment. This form will be faxed back to your office to confirm the date and time of appointment.
Section 1                                                                                                                            Today’s Date: ____________
Individual Completing Form: _______________________________	
Name of Referring Physician: ________________________    Name of Practice: _______________________________ Physician Phone Number: _______________________  	         Fax Number: ___________________________                  Is this physician the patient’s primary care provider?   Yes      No
Patient Information
Patient Last Name: ___________________________________ First Name: ________________________________ 
Street Address: _______________________________________________________City: _____________________ State: _________ Zip: _______________   SS Number: ________-________-_________ DOB: ____/_____/______          Marital Status:	 M    S     D        	 Maiden Name (if applicable): ____________________________________
Please Provide All Available Telephone Numbers for Contact
Home Phone: _________________ Work Phone: _____________________ Cell Phone: ________________________
Insurance Information
Primary Insurance Provider: _____________________________________________________________________
Group Number: ______________________________ Policy Number: ___________________________________
Name of Insured if different than above: _____________________________________________
Provider Services Phone Number: ___________________________________________________
Does this patient have Secondary Insurance?   NO    YES   Provider: _____________________________________
Group Number: ______________________________ Policy Number: ____________________________________
Primary reason for nutrition referral
□  Medical Nutrition Therapy for Diabetes– Initial Education (up to 3 hours) – billable to insurance
□  Medical Nutrition Therapy for Diabetes – Annual Follow Up (up to 2 hours) – billable to insurance
□  Medical Nutrition Therapy for Other Reason: _______________________________ - may or may not be 
	covered by insurance – specific reason will be discussed with patient and if not covered, nutrition 
             education will be offered
□  Nutrition Education for Reason: _______________________________________________ -  not covered by
           insurance, is always paid by patient – can be for any reason, including health eating

If referring for Diabetes: I certify that I am managing this patient’s diabetes and that the above prescribed therapy is necessary for management

____________________________________________________________		_____________________  Physician Signature									Date

Section 2 - For Use by Department Only
Date of appointment: ________   Time: ________ [ Medical Nutrition Therapy  Nutrition Education] 		
Date faxed back to referring physician: _____________________________	□  Unable to reach patient
If you have any questions, please call 
Summa Health System Outpatient Nutrition Services • 95 Arch Street, Suite 260 • Akron, OH 44304 
Phone (330) 375-6201 **** Fax (330) 375-3624