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Diabetes Prevention    Prior Authorization  
0           âœ†214-613-2019

Dpp-Enrollment

Diabetes Prevention Program (DPP)
Enrollment Form

Contact us @214-613-2019 or complete the form below to request enrollment in
our Diabetes Prevention Program, and a Prime Care Health Solutions team
member will reach out to you to complete your request.

Diabetes Prevention Program Form

Acknowledgement and Consent

Do Not Sign or Submit until You Have Read and agree with all policies and notices provided below. If you have any questions or concerns regarding our privacy policy, communication policy, or the terms of participation, please contact us at privacy@primecarehs.com
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Our privacy notice is available here, our HIPAA notice is available here, our terms of use document is available here, and our communication policy is available here
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Patient's Electronic Signature*
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Your full name with date serves as an electronic signature
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Personal Representative's Name
Personal Representative's Name
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Your full name with date serves as an electronic signature
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Relationship to Patient
Relationship to Patient
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Todays Date
Today's date*
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Appointment details

I am a*

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Appointment Location required*

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All initial appointments from a referring provider will be conducted in referring provider’s office location. For all other appointments for our clients near the DFW area, please visit us in our Dallas office. Otherwise, long-distance clients should consider the Skype option.
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Type of Service required (select all that apply)*

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To request an appointment, please fill out the form below. Our scheduling coordinator will contact you within 24-72 hours with your appointment options. If you would like to schedule your appointment immediately, please contact Prime Care Health Solution’s Help Desk: 214-613-2019.

For group programs, please indicate a preferred day and time
For private one on one appointment, please provide 3 preferred dates and time
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Type of reservation*

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GROUP Reservations only: Please provide a preferred day to meet
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PRIVATE APPOINTMENT only: Preferred Date (Option 1)
Select a date
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PRIVATE APPOINTMENT only: Preferred Date (Option 2)
Select a date
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PRIVATE APPOINTMENT only: Preferred Date (Option 3)
Select a date
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GROUP Reservations only: Preferred time of day
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PRIVATE APPOINTMENT only: Preferred Time (Option 1)
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PRIVATE APPOINTMENT only: Preferred Time (Option 2)
Select a time
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PRIVATE APPOINTMENT only: Preferred Time (Option 3)
Select a time
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Please note: While filling out this form does not guarantee appointment availability; it will expedite the scheduling process when speaking with a scheduling coordinator. We will do our best to accommodate your needs. Current clients may also book appointment times online by going to Book Appointment Now
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Patient demographics

Your First Name
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Your E-mail Address
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Your Address
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City
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Preferred contact method*
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How did you hear about us?
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What is your biological gender?*
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E.g for a height of 5 feet and 8 inches, enter 5 inches here and select 8 inches in the inches box.
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Height (feet)*
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Weight (lbs)*
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Your Last Name
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Your Phone number
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Country
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Zip / Postal code
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State / Province
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Date of Birth
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Body Mass Index (BMI)*
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You may click here for a body mass index (BMI) calculator
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Inches
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Medical History (Part 1)

Current medical conditions (Active)
Current medical conditions (Active)
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Family medical history (biological parents, siblings, aunts, uncles, grand-parents)
Family medical history (biological parents, siblings, aunts, uncles, grand-parents)
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Current prescription list (ex. Lisinopril 10 mg, 1 tablet daily for blood pressure)
Current prescription list (ex. Lisinopril 10 mg, 1 tablet daily for blood pressure)
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Recently discontinued (within last 3 months) prescription (ex. Lisinopril 10 mg, 1 tablet daily stopped for blood pressure)
Recently discontinued (within last 3 months) prescription (ex. Lisinopril 10 mg, 1 tablet daily stopped for blood pressure)
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Over-the-counter, vitamins, minerals, herbals, supplements (ex. Vitamin D 1000 IU, 1 tablet daily for bone health)
Over-the-counter, vitamins, minerals, herbals, supplements (ex. Vitamin D 1000 IU, 1 tablet daily for bone health)
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Allergies & Reactions
Allergies & Reactions
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Describe your current diet & exercise routines *
Describe your current diet & exercise routines *
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Brief description of your social, work and family life*
Brief description of your social, work and family life*
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Low energy, sluggish and usually tired though-out the day
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Low energy, sluggish and usually tired though-out the day
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Medical History (Part 2)

Which of the following health conditions apply to you? If you are unsure of the correct answer to a question, please check with your physician or another qualified health provider.
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Pre-diabetes: Blood test in the last year has shown you’re at risk for diabetes
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Gestational Diabetes: Diagnosed during a previous pregnancy
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High Birth Weight Baby: Have given birth to a baby weighing 9 pounds or more
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High or Abnormal Cholesterol: Your total cholesterol is greater than or equal to 200 mg/dL, your non-HDL cholesterol is greater than or equal to 160 mg/dL, or you take medicine to control your cholesterol.
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Low HDL: Your good cholesterol is too low. For women: HDL is less than 50 mg/dL. For men: HDL is less than 40 mg/dL.
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High LDL: Your bad cholesterol is too high: LDL greater than or equal to 130 mg/dL
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High Triglycerides: Blood test has shown triglycerides greater than or equal to 150 mg/dL
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High Blood Pressure or Hypertension: Systolic blood pressure of 130 or greater or diastolic blood pressure of 80 or greater that stays high over time
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Take Medicine to Control Blood Pressure: Prescribed medicine by a doctor to control blood pressure
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Tobacco Use: Current or former habitual use of cigarettes, pipes, cigars, or other tobacco products
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Have you been diagnosed with Type 1 Diabetes?
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Have you been diagnosed with Type 2 Diabetes?
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High or Abnormal Cholesterol
Select yes if any of the following are true: (1) You take medicine to control your cholesterol. (2) Total Cholesterol greater than or equal to 200 mg/dL (3) Non-HDL Cholesterol greater than or equal to 160 mg/dL
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Medical History (Part 3)

Please answer the following questions to the best of your knowledge. If you are unsure of the correct answer to a question, please check with your physician or another qualified health provider
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Over the next 6 months, do you anticipate NOT being able to engage in physical activity for 2 months or more (for example, due to a current injury or planned surgery)?
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Are you currently trying to conceive, are you pregnant or breast-feeding?
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Recent Cancer Treatment
In the last 6 months, have you undergone intensive cancer treatment, such as a bone marrow transplant, chemotherapy, radiation, or cancer-related surgery (not including hormonal chemotherapy like Tamoxifen)?
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Planned Cancer Treatment
Do you plan to go through intensive cancer treatment, such as a bone marrow transplant, chemotherapy, radiation, or cancer-related surgery (not including hormonal chemotherapy like Tamoxifen)?
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Organ Transplant
In the last 6 months, have you had an organ transplant (e.g. kidney or liver)?
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In the last 3 months, have you had any of the following?
(1) Transient ischemic attack or stroke (2) Heart attack (myocardial infarction) (3) Hospitalization for congestive heart failure (4) Cardiac surgery [such as coronary artery bypass grafting (CABG), coronary artery stenting]
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In the last 6 months, have you had any of the following?
(1) Bariatric/gastric bypass surgery (2) Gastric sleeve surgery (3) Gastric balloon procedure
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Are you currently on dialysis treatment?
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Do you have an active alcohol or substance abuse/dependence (that impairs ability to participate in the program)?
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In the last 12 months, have you received treatment for an eating disorder (e.g. anorexia or bulimia — not including binge-eating disorder)?
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Desired Outcomes

What health/wellness goal would you like to accomplish through the service you selected?*
What health/wellness goal would you like to accomplish through the service you selected?*
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What is your current motivator in seeking care with us and what has motivated you in the past in accomplishing your health/wellness goal?*
What is your current motivator in seeking care with us and what has motivated you in the past in accomplishing your health/wellness goal?*
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Provide a brief description of your social, work and family life*
Provide a brief description of your social, work and family life*
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What challenges and obstacles are you facing today in accomplishing your health/wellness goal?*
What challenges and obstacles are you facing today in accomplishing your health/wellness goal?*
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Social History

Are you single, married or divorced?*
Are you single, married or divorced?*
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Are you employed, unemployed or retired?*
Are you employed, unemployed or retired?*
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Do you drink alcohol?*
Please Select One
Please Select One
Do you smoke?*
Please Select One
Please Select One
Amount of cigarettes or packs you use per day
e.g. 20 cigarettes daily, or one pack daily
Amount of cigarettes or packs you use per day
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Number of years that you've smoked
Approximate duration in years since you've been smoking
Number of years that you've smoked
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Other substances that you may have used
Other substances that you may have used
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Do you have a history of substance abuse?*
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Primary Care Physician

Name, Address and phone number of primary care provider and all other health care provider or medical doctors*
Name, Address and phone number of primary care provider and all other health care provider or medical doctors*
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Primary Pharmacy

Name, Address and phone number of all pharmacies that provide your medications*
Name, Address and phone number of all pharmacies that provide your medications*
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Payment / Insurance Options

Who will be covering the cost of the service(s) you selected?*
If you are covering the cost by yourself, you will be redirected to a page where you can complete your enrollment and make a payment.
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Your medical insurance information
Please provide your medical insurance information for the selected service(s). Insurance name, primary carrier's name (insured), member ID number, group number, coverage date, effective date and customer service number.
Your medical insurance information
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Your pharmacy insurance information
Please provide your pharmacy insurance information for the selected service(s). Insurance name, primary carrier's name (insured), member ID number, BIN number, group number, coverage date, effective date and customer service number.
Your pharmacy insurance information
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Employer information*
Please provide the following details for your employer: Company name, company address, contact email, phone number.
Employer information*
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Thank you for enrolling in our services. After submission, you will be automatically redirected to a page where you can book your appointment with us. See you soon!
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Prime Care Health Solutions

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