DPP Patient Referrals

There are two ways HPSM members can be referred to the Diabetes Prevention Program:

Complete the Enrollment Form and email it to HealthEducationRequest@hpsm.org or FAX it to HPSM at 650-616-8235.
Complete and submit the program referral form below:

Fields marked with an asterisk (*) are required.

*Patient's name:

*Date of birth:

HPSM Member ID #:

Phone number:

Home address:

*Height:

Date measured:

*Weight:

Date weighed:

*BMI:

Date of BMI:

*Member must meet one of the following requirements:

1. Blood test in prediabetes range

HbA1c reading:

Date of HbA1c reading:

Fasting plasma glucose:

Date of reading:

2 hour plasma glucose:

Date of reading:

2. Previous gestational diabetes diagnosis (Medi-Cal members only): Yes No

Date of diagnosis:

*Provider's name:

Provider type:

Clinic:

*Phone number:

Fax number:

Email:

Primary care provider name: