CGM Order Form
Use this form to submit a prescription, start a new order, or to upload additional documentation for an existing order. This form is secure and HIPAA Compliant.
Customer Information
Customer Name
*
Cell Phone Number
*
*CGM resupply is managed through text message.
Format: (000) 000-0000.
Customer Email
Date of Birth
*
-
Month
-
Day
Year
Insurance Information
Would you like us to run your insurance eligibility?
Insurance Company Name
Insurance Member Name
Member ID
Group Number
Are you the subscriber?
Yes
No
If you would like to upload a photo of your insurance card, please submit it here.
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Submit Required Documentation for CGM
Which brand of CGM?
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ABBOTT FreeStyle Libre
DEXCOM CGM System
Which of the following criteria do you meet?
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Beneficiary has Type 1 or Type 2 diabetes and is insulin treated.
Beneficiary has Type 1 or Type 2 diabetes and has a history of problematic hypoglycemia with documentation of at least one of the following: Recurrent (more than one) level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan.
Beneficiary has Type 1 or Type 2 diabetes and has a history of one level 3 hypoglycemic event (glucose <54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia.
Documented Face-to-Face with Physician (Beneficiary must see treating practitioner every six months to continue to qualify.)
*
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Standard Written Order (Prescription)
*
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Additional Information
0/500
*
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