Reliable Diabetes Care - Change of Supplier Form

Change of Supplier Form
This form's purpose is to authorize the patient or patient's legal guardian the right to transfer from a previous medical equipment supplier to Reliable Diabetes Care for their Continuous Glucose Monitoring supplies. (procedure codes: A9278, A9277, A9276, E2103, A4239).

Consent to Transfer:

I (or my son / daughter) have been referred to Reliable Diabetes Care and would like to transfer to this company for future orders for my diabetes equipment needs.
Name of individual receiving equipment*

First NameLast Name
Relationship to patient*
Patient Date of Birth*

MonthDayYear
Date
Signature*

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Date*

MonthDayYear
Date
Previous supplier has been notified that patient is transferring off service*

YesNo
Name of previous DME supplier (if known)
Last order (if known)
Should be Empty: