NDPERS Sponsored Diabetes Management Program

INSTRUCTIONS TO COMPLETE FORM

Please either: read the wellness and enrollment form below, complete the fields below, and submit online, or print a copy, complete it, and bring it in to the provider you chose, or fax to the clinical coordinator, Frontier Pharmacy at 701-356-7458, or mail to:

Clinical Coordinator

Frontier Pharmacy Services, Inc.

3306 Sheyenne St, Suite 218

West Fargo, ND  58078

 NDPERS SPONSORED DIABETES MANAGEMENT PROGRAM

Member Wellness and Initial Enrollment Agreement

REQUIREMENTS

-Complete appropriate paperwork.  Provider or Clinical Coordinator can help you with this process.

-Schedule and attend all appointments with your provider.

-Schedule your first appointment within 7 days of enrollment acceptance and complete that appointment within 30 days of enrollment acceptance

-Supply your provider with all requested information, including lab results, medication lists, and health history.

-Meet with your provider on a regular basis

-Arrive 15 minutes prior to your appointment to complete paperwork

-Be actively involved in your diabetes management and work to achieve established goals.

 BENEFITS

-Better health!

-Reimbursement of co-pays for diabetic medications and certain kidney protecting medications upon completion of your first scheduled appointment.

-Education classes with your provider

 RIGHTS

-You have the right to be an active participant in your health care

-You have the right to remove yourself from the program at any time

-You have the right to choose your provider and to change providers if desired

CANCELLATIONS AND MISSED APPOINTMENTS

Patients and providers are busy people.  Therefore, it is crucial that we respect each other’s time.  The following is a requirement of participants:

-A 24 hour notice must be given to your provider if you are unable to make a scheduled appointment (unless it is an emergency situation, then let them know as soon as possible).

-Upon a missed appointment without prior notification, the program clinical coordinator will contact you with a warning about continuing in this voluntary program.

-A second missed appointment without prior notification will result in your program termination.

-If you choose not to be a part of the program, you will not continue to receive co-pay reimbursements.

-If you choose not to be a part of the program, you may choose to re-enroll after a 3 month waiting period if there are spaces available in the program (enrollment is limited to 800 members).

-When an appointment is needed to be scheduled, a message may be left for you.  It is very important that you respond to that message in a timely manner (within 7 days).  Failure to respond will result in a letter from the clinical coordinator.  If you fail to respond to the request of the clinical coordinator within 7 days, it will be assumed that you do not want to continue in the program and you will be dropped from the program.  You may choose to re-enroll after a 3 month period.

COMPLETE THE INFORMATION BELOW TO SUBMIT YOUR ENROLLMENT INFORMATION: