PHYSICIAN ORDER FOR CGM SUPPLIES (MEDICARE)
This form is required to ensure that the patient receives full Medicare or other insurance benefits.
Patient Information
Name
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First Name
Middle Name/Initial
Last Name
Patient Date of Birth
*
/
Month
/
Day
Year
Date
Patient Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
*
Format: (000) 000-0000.
Medicare Beneficiary ID (MBI)
*
Diagnosis (select one):
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E11.9/250.00 Type 2 diabetes mellitus without complications
E10.9/250.01 Type 1 diabetes mellitus without complications
E11.65/250.02 Type 2 diabetes mellitus with hyperglycemia
E10.65/250.03 Type 1 diabetes mellitus with hyperglycemia
Other
Please provide clinical notes verifying the following details (all must be checked to qualify for Medicare):
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The patient has diabetes mellitus.
The patient (or caregiver) has received sufficient training using the CGM as evidenced by a prescription.
The CGM is prescribed in accordance with its FDA indication for use.
Within six (6) months prior to ordering the CGM, the treating practitioner has conducted an in-person or Medicare-approved telehealth visit with the patient to evaluate their diabetes control and determined criteria (1-4) above are met.
Every six (6) months following the initial prescription of the CGM, the treating practitioner will have an in-person visit with the patient to assess adherence to their CGM regimen and treatment plan.
Date of last diabetes evaluation
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Month
-
Day
Year
Date
The patient meets at least one of the criteria below (minimum 1 required):
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The patient is insulin-treated
The patient has a history of problematic hypoglycemia documented by: Recurrent level 2 hypoglycemia events (<54mg/dL persisting despite multiple attempts to modify medications and/or the diabetes treatment plan) and/or
The patient has a history of problematic hypoglycemia documented by: History of one level 3 hypoglycemic event (glucose <54mg/dL characterized by altered mental status and/or physical state requiring third-party assistance for hypoglycemia treatment
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Product Selection
Tyson Drugs pharmacists recommend the Dexcom
Product Information (select products or leave blank for supplier to assist):
Dexcom G6/G7 Receiver (E2103) Qty: 1 unit
Dexcom Transmitter and Sensors (A4239), Qty: 3 units (90 day supply), Directions: Replace sensor every 10 days
FreeStyle Libre 2 Reader (E2103), Qty: 1 unit
FreeStyle Libre 2+ Sensors (A4239), Qty: 3 units (90 day supply), Directions: Replace sensor every 15 days
FreeStyle 3 Reader (E2103), Qty: 1 unit
FreeStyle 3+ Sensors (A2439), Qty: 3 units (90 day supply), Directions: Replace sensor every 15 days
Other
Physician Information
Physician Name
*
NPI
*
Clinic Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Office Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Ordering Physician attests to the following:
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The treating provider hereby confirms that the patient’s diabetic condition warrants the need for Continuous Glucose Monitoring (CGM) as evidence by the ICD-10 code(s) selected above and clinic notes supporting the listed criteria.
The treating provider hereby confirms that he/she is treating the above patient under a comprehensive plan of care for his/her Diabetes Mellitus. He/she has met with the patient within six months prior to ordering CGM, and he/she will continue to meet with the patient every six months from the time the initial order was written.
Signature
*
Date
*
/
Month
/
Day
Year
Date
Send order to:
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Tyson Drugs, 145 E Van Dorn Ave, Holly Springs, MS
G&M Pharmacy, 2159 S Lamar Blvd, Oxford, MS
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