Diabetes Partnership Agreement for Nurse Practitioners

Below is a diabetes partnership agreement that I found on I changed the wording to say health care provider instead of physician to include nurse practitioners because we provide the same care for diabetics. Hope it is helpful. I think that it is a great template for other health issues as well.

Patient-health care provider partnership agreement for diabetes management

OBJECTIVE
To better manage your diabetes through a patient-physician partnership and goal setting.

REASON
Medical research and clinical experience have shown that optimal management of diabetes significantly reduces the known
complications of this disease, including blindness, heart attack, kidney failure and loss of a limb.

EXPECTATIONS
You can expect your physician to provide the following services, which are an essential part of diabetes management.
• OFFICE VISITS - every three months for reviewing your progress.
• MONITORING - blood pressure, other vital signs, foot examination and A1C.
• ANNUAL SCREENING - lipids, microalbuminuria (test for kidney protein), eye examination and monofilament testing (sensory
examination of feet).
PERSONAL GOALS
Weight/Body Mass Index: Current:________/________ Ideal:________/________
A1C (< 6.0 percent): Current:__________ Goal for 6 months:__________
Blood pressure (< 130/80 mm/Hg): Current:__________ Goal:__________
Total cholesterol (< 200 mg/dl): Current:__________ Goal:__________
LDL (< 100 mg/dl): Current:__________ Goal:__________
YOUR RESPONSIBILITIES
• Schedule follow-up appointments every three months or as indicated by your doctor.
• Monitor blood sugars at home at the agreed testing frequency: _____________________.
• Work toward attaining the personal goals noted above.


PATIENT SIGNATURE _________________________________________ Date:______________
HEALTH CARE PROVIDER SIGNATURE ______________________________________ Date:______________