Vital Health Medical Supply — CGM Provider Referral & Standard Written Order

Vital Health Medical Supply — CGM Provider Referral & Standard Written Order

Submit a secure CGM referral and supporting records for intake review, including the standard written order details.
Referral office and submitter
Practice / Facility Legal Name
Practice Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Main Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secure Fax
Please enter a valid phone number.Format: (000) 000-0000.
Submitter Full Name

First NameMiddle NameLast Name
Role / Title
Direct Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secure Email
example@example.com
Submitter Relationship to Ordering Practitioner
Preferred Follow-up Method for Missing Documents
Office contact for missing documentation
Office direct phone
Please enter a valid phone number.Format: (000) 000-0000.
Office secure email
example@example.com
Referral Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient demographics
Patient legal name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Service/shipping address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred language
Medicare Beneficiary Identifier or insurance member ID
Primary payer
Primary plan name
Primary member ID
Primary group number
Upload front of primary insurance card

Cancelof
Upload back of primary insurance card

Cancelof
Does the patient have secondary insurance?
Secondary payer
Secondary plan name
Secondary member ID
Secondary group number
Upload front of secondary insurance card

Cancelof
Upload back of secondary insurance card

Cancelof
Diagnoses and clinical screening
Diabetes diagnosis

Another ICD-10-CM code
ICD-10-CM code(s)
Date of diabetes diagnosis

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current diabetes treatment

Other
Insulin name(s)
Insulin prescribed frequency or regimen
Insulin-treated
Documented history of problematic hypoglycemia
If yes, qualifying hypoglycemia history
Date(s) and details of hypoglycemia events

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Supporting documentation for hypoglycemia history

Cancelof
Documented problematic hypoglycemia?
Date of most recent in-person or telehealth diabetes follow-up

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Clinical rationale / medical necessity
Current CGM supplier
Date of last CGM shipment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Overlap warning acknowledgment
Is the patient currently receiving CGM supplies from another supplier?
Sensor item/brand description
Sensor quantity to dispense
Sensor replacement/refill frequency
Sensor number of refills
Transmitter item/brand description
Transmitter quantity to dispense
Transmitter replacement/refill frequency
Transmitter number of refills
https://vital-health-services-dme.fadizue.chatgpt.site/notice-of-privacy-practices.html
CGM evaluation, training, and follow-up attestations
CGM standard written order
Order date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Requested CGM system
Receiver needed?
Sensors
Transmitter (if applicable)
Other related diabetes supplies
Length of need

Other
Substitution / equivalent product instruction
Allergies or skin / adhesive concerns
Special delivery or accessibility instructions
Disclaimer
Supporting records upload
Do not email PHI separately; upload through this secure form or use Vital Health’s secure fax.
Signed prescription or order

Cancelof
Most recent diabetes office note

Cancelof
Medication or insulin list

Cancelof
Blood glucose or hypoglycemia documentation (if applicable)

Cancelof
Prior authorization or payer-specific form (if available)

Cancelof
Other supporting documents

Cancelof
Ordering practitioner
Practitioner full legal name

First NameMiddle NameLast Name
Credentials
Individual NPI
Specialty / taxonomy
Practice address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Practice phone
Please enter a valid phone number.Format: (000) 000-0000.
Fax number
Please enter a valid phone number.Format: (000) 000-0000.
PECOS enrollment confirmed if Medicare applies
State license number
State of license
Practitioner electronic signature
Final office checklist
Checklist confirmations
Practitioner attestation
Are the patient demographics verified?
Referral/intake only — not a valid signed order unless separately signed by the practitioner.
Practitioner signature date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are insurance cards attached?
Is a recent clinical note attached?
Who is signing/submitting this form?
Is the signed order completed or attached?
Is insulin regimen or hypoglycemia documentation included when applicable?
Should be Empty:

Vital Health Medical Supply — CGM Provider Referral & Standard Written Order

Referral office and submitter

Patient demographics

Diagnoses and clinical screening

CGM standard written order

Supporting records upload

Ordering practitioner

Final office checklist