United Healthcare Community Plan of Virginia

Diabetes Management Assessment Form

  Participating pharmacies and patients must be approved for participation by United Healthcare Community Plan of Virginia. Please verify eligibility with program administrator prior to submitting.
  Instructions for completing the Diabetes Management Assessment Form:
  Gather information from multiple sources including existing patient records and other health care professionals
    - Conduct a medication history interview with the patient
    - For each medication, gather information on adherence, effectiveness, potential side effects (i.e., safety), and whether it can be taken as intended (e.g., access and affordability)
    - Inquire as to who primarily manages the patient's medications and how this process works (e.g., pill boxes, calendars, reminders)
    - Ask what the patient's own goals are for his/her health
    - Obtain information about patient's diabetes (e.g., history of hospitalizations in the past six months, frequency of blood sugar / A1c testing, baseline activity level, etc.)
    - Obtain any necessary lab values and/or measurements (e.g., baseline blood sugar, A1c, blood pressure)
    - Conduct any necessary physical assessments (e.g., foot exam)
  All submissions must include a completed care plan assessment.
  Please download and complete the assessment form, available below, or upload care plan document created through your clinical software program.

Note : All the below fields are Required

Please complete the following information:

Pharmacy Name:

Patient Demographic/Info:

Pharmacy NPI:

Patient Full Name:

Primary Care Provider Name:

Patient DOB:
(mm/dd/yyyy)

Prescriber Managing Diabetic Medications:

Patient Contact Address:

Other Pharmacies Filling Prescriptions:

YES NO

Patient Contact Phone Number:
(xxx-xxx-xxxx)

Most Recent HbA1c Value:
(00.0% - mm/dd/yyyy)

Patient Medicaid ID:

Assessment Type:
Initial assessment (must include initial A1C) Routine monthly assessment Final assessment (must include final A1C)

Date of Assessment:
(mm/dd/yyyy)

CPESN - Diabetes Management and Education: Initial Assessment Form -- Download and Upload:

Click Link to download form

Upload File :(Max file size limit is 1 MB)

I attest that the information provided is complete, accurate and up to date.

Pharmacist Name:

VA License Number :

CPESN Email: