Vital Health Medical Supply — CGM Eligibility & Supply Request

Vital Health Medical Supply — CGM Eligibility & Supply Request

Complete this short intake to request an insurance coverage review for CGM supplies (not an emergency form).
Who is Completing This
Who is completing this form?
Submitter full name

First NameLast Name
Relationship to patient
Submitter phone number
Please enter a valid phone number.Format: (000) 000-0000.
Submitter email address
example@example.com
Patient Information
Legal First Name
Legal Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Service / Shipping Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Contact Method

Other
Preferred Language
North Carolina Resident
Insurance
Primary insurance type

Other
Payer/plan name
Member ID
Group number
Upload front of primary insurance card

Cancelof
Upload back of primary insurance card

Cancelof
Does the patient have secondary insurance?
Secondary payer/plan name
Upload front of secondary insurance card

Cancelof
Upload back of secondary insurance card

Cancelof
Diabetes and CGM Screening
Has a healthcare practitioner diagnosed diabetes?
Diabetes type
Current diabetes treatment

Other
If using insulin injections, how many times per day?
If using insulin, list insulin name(s)
If using insulin, are you unsure of the insulin name(s)?
Has the patient experienced documented problematic hypoglycemia?
Current CGM use
Requested or preferred CGM system
Final product is subject to prescription, coverage, compatibility, availability, and clinical appropriateness. Notice of Privacy Practices: https://vital-health-services-dme.fadizue.chatgpt.site/notice-of-privacy-practices.html
Does the patient have a compatible smartphone?
May a dedicated receiver be needed?
Date of most recent diabetes visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Treating practitioner full name
Treating practitioner practice name
Treating practitioner phone
Please enter a valid phone number.Format: (000) 000-0000.
Treating practitioner fax (if known)
Practice city
Practice state
Permission for Vital Health to contact the practitioner and insurer for prescription, documentation, benefit verification, authorization, treatment, payment, and healthcare operations
Authorized to act for the patient
Policyholder full name
Policyholder date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policyholder relationship to patient
Vital Health Medical Supply — CGM Eligibility & Supply Request
Is the patient the primary insurance policyholder?
Secondary member ID
Secondary group number
Overlapping-supplier warning
Current Supplier and Timing
Is the patient currently receiving CGM supplies from another supplier?
Current supplier name
Date of last shipment, if known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for requested change
When are supplies needed?
Additional comments
Acknowledgments and Electronic Signature
Acknowledgment statements
Consent to be contacted by phone calls
Consent to be contacted by secure email
Consent to receive text messages
Signature
Printed name

First NameMiddle NameLast Name
Relationship to patient
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Vital Health Medical Supply — CGM Eligibility & Supply Request

Who is Completing This

Patient Information

Insurance

Diabetes and CGM Screening

Current Supplier and Timing

Acknowledgments and Electronic Signature