Provider Referral Form:

Comprehensive Diabetes & Nutrition Education Program

Enhancing Patient Care through Expert Guidance & Personalized Services

Our multidisciplinary team of diabetes and nutrition experts is dedicated to providing comprehensive and personalized care for your patients. Through our Medical Nutrition Therapy (MNT) and Diabetes Self-Management Education (DSME) services, we empower individuals with the knowledge and skills they need to manage their diabetes, while offering you, the provider, valuable support in delivering top-tier care.

We Accept The Following Insurance

  • Aetna

  • Ambetter (Superior Health)

  • Baylor, Scott & White

  • Blue Cross Blue Shield

  • Cigna

  • Golden Rule

  • Medicare

  • Optum

  • Oxford

  • United Healthcare

  • United Medical Resources

To refer your patient to our Medical Nutrition Therapy (MNT) and Diabetes Self-Management Education (DSME) programs, please utilize the HIPAA-compliant form provided below. Once submitted, Balance Diabetes Wellness will promptly verify the patient’s health insurance benefits and contact them to schedule an appointment. By teaming up with us, you can elevate your care delivery and ensure that your patients receive the comprehensive support necessary for effectively managing their diabetes.

If you’d prefer to print and fax, here’s the PDF link.

Please Fill in the Patient's Information Below: