UNMC's Diabetes Prevention Program at EngAge Wellness Physician Authorization Form

Patient Name:
Date of Birth:
Phone Number:

Your patient may be eligible to participate in the University of Nebraska Medical Center Diabetes Prevention Program at EngAge Wellness. The one-year program is part of the National Diabetes Prevention Program, led by the Centers for Disease Control and Prevention (CDC). It is a proven lifestyle change intervention that has been shown to prevent or delay type 2 diabetes in high-risk patients.

UNMC's Diabetes Prevention Program is based on research examining the effects of structured lifestyle change interventions. The research showed that weight loss of 5 to 7 percent of body weight, achieved by reducing calories and increasing physical activity to at least 150 minutes per week, reduced the risk of developing type 2 diabetes by 58 percent in people at high risk for the disease. For people over 60 years old, the program reduced risk by 71 percent. A follow-up study found, after 10 years, those who had participated in the earlier lifestyle change intervention had a 34 percent lower rate of type 2 diabetes.

Participants meet in groups with a trained lifestyle coach once a week for 16 weeks and then once a month for 8 months to learn ways to incorporate healthier eating, moderate physical activity, problem-solving and coping skills into their daily lives.

In addition, patients participating in the Diabetes Prevention Program are given the option of a discounted three-month introductory trial participation in the EngAge Wellness program (if they are not already a participant), where they receive an individualized fitness program.

Physician Authorization

My patient has my approval to participate in the UNMC Diabetes Prevention Program based on the following eligibility criteria:
BMI > 24 kg/m2 (> 22 if Asian),


Diagnosis of prediabetes or GDM based on (Please provide number or check for GDM or Screening Test)
Fasting blood glucose (range 100-125 mg/dl)
2-hour glucose of (range 140-199 mg/dl)
HbA1c of (range 5.7-6.4)
Previous Gestational Diabetes Mellitus (may be self-reported)


A score of 9 or higher on the CDC Prediabetes Screening Test (patient self-assessment)
Physician's Name:
License Number:
Physician Group/Location:
Phone Number:
Fax Number:
Date: 10/17/2021

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Form last updated 04/03 /18

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