*合格提供商的签名证明了他或她正在管理受益人的DSMES/T转介的糖尿病护理。Provider's Name (Printed): _________________________________ Provider's NPI # :___________________ Group/Practice Name:_______________________________________________________________________ Phone Number:__________________________________ Fax Number:________________________________ Provider's Signature ________________________________________________ Date _____ / _____ / ________
主要关键词