Diabetes Center

Diabetes Center Forms

To assist our families and referring physicians, the Diabetes Center at Cincinnati Children's Hospital Medical Center provides many of its forms online.

Portable document format icon. You can download the following Diabetes Center forms in portable document format (.pdf):

Medical Forms
Diabetes Dilated Retinal Exam Consultation Request (65k)

School Forms
Authorization for Use or Disclosure of Protected Health Information to Schools (HIPAA form) (237k) Diabetes Care at School Instructions (68k) Hyperglycemia Emergency Plan (60k) Returning to School with Diabetes Instructions / Form (48k) Glucagon Emergency Kit Instructions Calculation Sheet for Rapid Acting Insulin Physical Activity Guidelines for Students with Diabetes (161k) Diabetes Center Terminology for Schools (67k) Diabetes Monitoring Log for Schools (47k) Insulin Dose Order for Nurse-Assisted Insulin Administration in Kentucky Schools (40k) Diabetes ID Sheet: Diabetes ID Sheet for Basal / Bolus Insulin Therapy (86k) Diabetes ID Sheet for Insulin Pump Therapy (86k) Diabetes ID Sheet for Split / Mixed Therapy (85k) Hypoglycemia Emergency Plan: Hypoglycemia Emergency Plan for Basal Bolus or Insulin Pump Therapy (69k) Hypoglycemia Emergency Plan for Split Mixed Therapy (70k) Individual Health Management Plans: Individual Health Management Plan for Basal / Bolus Insulin Therapy (60k) Individual Health Management Plan for Insulin Pump Therapy (58k) Individual Health Management Plan for Split / Mixed Therapy (56k)

School Forms

Authorization for Use or Disclosure of Protected Health Information to Schools (HIPAA form) (237k)
Diabetes Care at School Instructions (68k)
Hyperglycemia Emergency Plan (60k)
Returning to School with Diabetes Instructions / Form (48k)
Glucagon Emergency Kit Instructions
Calculation Sheet for Rapid Acting Insulin
Physical Activity Guidelines for Students with Diabetes (161k)
Diabetes Center Terminology for Schools (67k)
Diabetes Monitoring Log for Schools (47k)
Insulin Dose Order for Nurse-Assisted Insulin Administration in Kentucky Schools (40k)
Diabetes ID Sheet:
Hypoglycemia Emergency Plan:
- Hypoglycemia Emergency Plan for Basal Bolus or Insulin Pump Therapy (69k)
- Hypoglycemia Emergency Plan for Split Mixed Therapy (70k)
Individual Health Management Plans:

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