Health Care Provider Referral

Participation Requirements

To qualify for the Diabetes Prevention Program, participants must be 18 or older, overweight/obese (having Body Mass Index greater than 25 or 22 for Asian Americans) and at high risk for developing type 2 diabetes, or have been diagnosed with prediabetes. The program is open to all individuals through the Y regardless of their insurance status. YMCA membership not required.

Please provide the patient with one of the following blood results.

• Fasting plasma glucose between 100 and 125 mg/dL
• Oral Glucose Tolerance Test between 140 and 199 mg/dL
• HbA1c between 5.7 and 6.4 percent

Provider Referral Form

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