DPP Patient Referrals

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

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

Diabetes Prevention Program Patient Referral Form

Fields marked with an asterisk (*) are required.

*Member must meet one of the following requirements:

1. Blood test in prediabetes range

2. Previous gestational diabetes diagnosis (Medi-Cal members only):

Referring provider or facility