Applying is easy
Just answer each question and click the Apply Now button at the end

If you would like to print out and mail the forms instead of submitting online, click here.

Please choose your employer*

Please choose which program you are applying for

CONTACT INFORMATION *indicates required field

Please choose your status*

Do you have any plans to leave the State of Maine for one month or longer while you are participating in this program?


PERSONAL CHARACTERISTICS
  1. What is your sex?*

Which of the following best describes you?*

  1. Occupation*

Work Schedule Hours*

  1. Is English your primary language for reading and writing?*
  1. Would you like to use email and a computer for communication when possible?*
  1. Have you previously had diabetes education?*


  1. What kind of diabetes do you have?*
  1. About how long have you had diabetes?*
  1. Do you use an insulin pump?*
  1. Do you have high blood pressure?*
  1. Do you have high cholesterol?*
  1. Do you have other health problems?*


  1. Please list all medications that you take
  1. Please add any other comments or questions you may have
PLEASE SELECT YOUR CHOICE OF EDUCATIONAL PROGRAMS FROM THE FOLLOWING LOCATIONS*
AUTHORIZATION STATEMENT(S)

Please read the following statement, check the box below, and sign and date where indicated at the end

  • I understand that these diabetes education and support services are voluntary programs.
  • I understand that completion of the application is a condition of participation.
  • I understand that I can withdraw from the program at any time by communicating my wishes with the diabetes educator.
  • I understand you will contact my doctor for his/her approval of my entry into the diabetes program.
  • I understand that my personal information will be kept confidential and only shared with my diabetes educators and my personal doctor.
  • I agree to communicate at least monthly with a diabetes educator, usually by telephone.
  • I agree to participate in the diabetes education and support process to the best of my ability.
  • I understand if my first appointment is between the 1st and the 22nd day of the current month, the waiver of co-pays will begin on the 1st of the following month. If my first appointment is between the 23rd of the current month and the 22nd day of the next month, the waiver of co-pays will be the 1st of that following month. Examples: First Appointment is from Jan. 1 to Jan. 22nd , waiver begins Feb . 1. First Appointment is from Jan. 23rd to Feb. 22nd , waiver begins on March 1st. First Appointment is from Feb. 23rd to March 22nd waiver begins on April 1st. The waiver of co-pays will continue for a twelve month period if I remain actively involved in the program by participating in regular phone calls with the diabetes educator.
  • I also understand if my insurance coverage should change during my enrollment, I must notify MCD immediately to determine if I will continue to qualify for the program.

, I understand


I hereby authorize Medical Care Development, Inc. to release my personal information to participating clinicians and hospitals for the purpose of my participation in the Telephonic Diabetes Education Program and Support Program (TDES©) for persons with diabetes or the Telephonic Diabetes Education/+Cardiovascular Disease (TDES©/+CVD) for persons with diabetes and high blood pressure and/or high cholesterol. I understand that my eligibility for benefits, processing and payment of claims, or treatment is not conditioned on giving this authorization or revocation of this authorization. However, if I do not give this authorization or if I revoke this authorization, I will not be allowed to participate in the TDES© or the TDES©/+CVD program.


A copy of this Application and Authorization is available to me, or to my authorized representative, upon request and will serve as the original. I understand that if this information is to be received by individuals or organizations that are not health care providers, health care clearinghouses, or health plans covered by federal privacy regulations, my information may be re-disclosed by the recipient and no longer protected by federal privacy regulations.


I have the right to cancel this release of information/authorization at any time, except to the extent that the person/company has already taken action on the disclosure provisions contained in this document. If I choose to cancel the release of information/authorization, I must notify Medical Care Development in writing that I request a cancellation of this release of information/authorization. This Authorization shall remain effective until revoked in writing by me.


Persons or Entities Disclosing or Receiving Protected Health Information

  1. The Protected Health Information identified below may be used and/or disclosed TO the following persons or entities. Name & Address: MCD Public Health/TDES© Program, 11 Parkwood Dr., Augusta Me 04330 and the diabetes education center from whom I receive services.
  2. The Protected Health Information identified below may be disclosed FROM the following persons or entities (Family Doctor & diabetes education center from which I receive services)

Please enter your Family Doctor's Name


Please enter your Family Doctor's Address


Please enter your Family Doctor's Phone

  1. Purpose - The identified information may be used and/or disclosed for the following purpose(s): For enrollment in and evaluation of the Telephonic Diabetes Education and Support© Program offered through MCD Public Health and the Diabetes Education site I have selected on the application form.

Specific Authorization to Disclose

I hereby authorize any and all of my health care practitioners and health care facilities to furnish, discuss, use and/or disclose the following (Please choose DO or DO NOT from dropdowns below)*

  1. I authorize the use/disclosure of my complete record including all records of any other health care provider in the possession of the above named provider and all protected health information. (NOTE: Even if you select "I Do" please complete 2, 3, and 4 in this section. Failure to complete these sections is deemed a refusal to authorize the disclosure for that information)
  2. I authorize the use/disclosure of information, which relates to testing, diagnosis, or treatment of HIV infection, AIDS-related complex or AIDS.
  3. I authorize use/disclosure of information, which relates to treatment or diagnosis of substance (drug or alcohol) abuse.
  4. I authorize use/disclosure of information, which relates to treatment or diagnosis for mental health.

If you want us to only use and/or disclose specific protected health information, complete the following

  1. I authorize the use and disclosure of only specific protected health information, which I am describing below.

Understanding Your Rights

I Understand

  1. Redisclosure of Information - Any information used and/or disclosed may be subject to redisclosure by the Recipient and may no longer be subject to HIPAA's protections.
  2. Revocation - I understand that I may revoke this Authorization, in writing, at any time, by sending a signed, written notification of revocation to the Health Care Provider. I understand that, if I revoke this Authorization, it will not affect actions or disclosures already taken by the Health Care Provider in reliance on the Authorization prior to the Health Care Provider's receipt of the revocation. I understand that the revocation will not be effective if the Authorization was obtained as a condition of obtaining insurance coverage, to the extent that other law provides the insurer with the right to contest a claim under the policy or the policy itself. I also understand that revocation of this Authorization may be the basis for denial of health benefits or other insurance coverage or benefits.
  3. Right to Refuse Authorization-I understand that I may refuse to authorize the use and/or disclosure of all or part of my health information, but such refusal may result in improper diagnosis or treatment, denial of coverage or a claim for health benefits or other insurance, or other adverse consequences.
  4. Authorization Not Required-I understand that the Health Care Provider will not condition my treatment, payment, enrollment in a health plan or eligibility for benefits (if applicable) on whether I provide authorization for the requested use or disclosure, except: (a) if my treatment is related to research, then an authorization may be required; or (b) if the purpose of the health care is solely to create PHI to provide the PHI to a third-party, then an authorization may be required.
  5. Expiration of Authorization - I understand that this Authorization shall be in effect until the date OR event set forth below, whichever occurs earlier, at which time this Authorization shall expire.  Except as may otherwise be permitted under Maine law, this Authorization is NOT valid for more than thirty (30) months from the date signed.
  6. Copy of Authorization - I understand that I have a right to receive a copy of this Authorization.
  7. Voluntary - I understand that I am voluntarily executing this Authorization.

Please agree to the above by typing your name below*


And please enter today's date*