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hUtnCVtmRLnJdsiA9h7A92ZqV5d4ER9j4FCZmdtK5g6VfTCEWJYEHKqxLLYMKe8YNkMGz3oW

SHINE Program Enrollment Form

Please complete the survey below.

Thank you for your interest in joining the SHINE Program - supporting health improvement, nutrition and exercise!

Please complete this online enrollment form so we have your demographic and program eligibility information on file.

Thank you for choosing to enroll in the MUSC SHINE Diabetes Prevention Program. SHINE stands for Supporting Health Improvement, Nutrition and Exercise. We are certified as a CDC National Diabetes Prevention Program (DPP).

As a National DPP, we are required to report ANONYMOUS participant demographic, weight, exercise, A1C, and other data to the CDC, as the CDC evaluates our program to ensure we are helping our participants reduce or delay the onset of type 2 diabetes.

We will also ask you for your Medicare Beneficiary ID number (MBI) IF you have Medicare Part B insurance, as Medicare may cover the cost of your participation in our DPP. If you do not have Medicare insurance, you can leave this question blank. Unfortunately, no other insurance plans cover the cost of DPP at this time in South Carolina.

Thank you for completing our enrollment form. We MUST have a complete enrollment form for each person that wishes to participate in the MUSC SHINE DPP. Thank you for your understanding.

First Name

* must provide value

Last name

* must provide value

What was the most motivating factor in determining your choice to enroll in the Diabetes Prevention Program?

* must provide value

Did a health care professional make a referral for you to join the DPP?

* must provide value

Age

* must provide value

Please enter your height in feet and inches in the following questions.

Current height (feet)

* must provide value

Current height (inches)

* must provide value

Current weight (in pounds)

* must provide value

Height_tot_in

View equation

BMI

View equation

If you have had an A1c blood test in the past 12 months, please report your A1c blood test result. This information is necessary for program enrollment and to ensure Medicare coverage.

Ethnicity

* must provide value

Race

* must provide value

American Indian or Alaska Native

Asian or Asian American

Black or African American

Native Hawaiian or Other Pacific Islander

White

Not reported

Gender

* must provide value

Have you ever been diagnosed with gestational diabetes?

* must provide value

Yes

Not applicable

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Education

* must provide value

Please enter your address below

Please enter your street

* must provide value

Please enter your City

* must provide value

Please enter your state, using the two digit postal code. (such as for South Carolina- SC)

* must provide value

Please enter your five digit zip code

* must provide value

Primary phone number (including area code)

* must provide value

Email address

* must provide value

Insurance provider

* must provide value

IF you plan to use your Medicare Part B or Medicare Advantage plan to cover the cost of DPP, please enter your current Medicare Beneficiary ID number so that we can validate your insurance coverage.

Have you ever been diagnosed with high blood pressure?

* must provide value

Yes

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Have you ever been told by a health care professional you have diabetes, or a touch of the sugar?

* must provide value

Yes

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Do you have a mother, father, sister, or brother with diabetes?

* must provide value

Yes

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What is the name of your primary care provider?

* must provide value

If you have your primary care provider phone number, please list.

Have you ever participated in a diabetes prevention program class similar to SHINE? If a claim has been previously submitted for such a program, we need to know for Medicare billing compliance.

* must provide value

Yes

reset

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.