MEDICARE DME ORDER FORM
DO NOT LEAVE ANY SPACE BLANK
Submission Date
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Month
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Day
Year
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Patient Information
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FIRST NAME
LAST NAME
DOB
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LAST 4 SNN
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ADDRESS
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CONTACT INFO
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Phone number with area code included
EMAIL
PRIMARY INSURANCE NAME
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PRIMARY INSURANCE ID #
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SECONDARY INSURANCE NAME
SECONDARY INSURANCE ID#
DIAGNOSIS/ICD-10 CODE
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STATEMENT OF MEDICAL NECESSITY (to be eligible, BOTH boxes need to be checked)
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Patient's insulin treatment requires frequent adjustment based on BGM or CGM testing results.
Patient has received or has scheduled diabetes education specific to CGM usage and/or received ongoing instruction specific to CGM usage and ongoing adherence to usage of CGM.
CHECK ALL THAT APPLY:
History of severe glycemic excursions
History of hypoglycemic unawareness
Recurring episodes of severe hypoglycemia
Patient has been hospitalized or has required paramedical treatment for low blood sugar
Day-to-day variations in work and lifestyle schedule, which confound the degree of regimentation required to self-manage glycemia w/ multiple insulin injections.
Currently on CGM therapy?
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YES
NO
Currently on Insulin Pump?
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YES
NO
Date of last visit (Must be within 6 months of order)
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Month
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Day
Year
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Number of Injections per Day.
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MINIMUM ONE INSULIN INJECTION PER DAY
Number of Self-Monitoring Blood Glucose Tests/day
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HbA1c
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CGMS: Choose 1 Brand only
DEXCOM G6 CGMS
E2103 - RECEIVER (Monitor) / Sig: Dispense 1; Refill:0; Use per Manufacturer Instructions; 1/365 days
A4239 - TRANSMITTER / Sig: Dispense 1; Refill:3; Use 1 transmitter every 90 days; 4/365 days
A4239 - SENSORS / Sig: Dispense 9; Refill:3; Use 1 sensor every 10 days; 365/365 days
Dexcom G7 CGMS *****
FREESTYLE LIBRE 2 CGMS
E2103 - RECEIVER (Monitor) / Sig: Dispense 1; Refill:0; Use per Manufacturer Instructions; 1/365 days
A4239 - SENSORS / Sig: Dispense 7; Refill:3; Use 1 sensor every 14 days; 365/365 days
Freestyle Libre 3+ (NEW) / Sig: Dispense 6; Refill: 4; Use 1 sensor every 15 days; 365/365 days
INSULIN PUMP: OMNIPOD BRAND ONLY
OMNIPOD DASH
E0784- PODS / Sig: Dispense 30; Refill:3; Use 1 pod every 3 days; 120/365 days
OMNIPOD 5 G6 DEXCOM
E0784- PODS / Sig: Dispense 30; Refill:3; Use 1 pod every 3 days; 120/365 days
OMNIPOD 5 G6 DEXCOM KIT + REFILLS (NEW START)
E0784- PODS / Sig: Dispense 30; Refill:3; Use 1 pod every 3 days; 120/365 days
E0784- KIT / Sig: Dispense 1; Refill:0; Use 1 pod every 3 days; 120/365 days
THIS DOCUMENT SERVES AS A PRESCRIPTION AND STATEMENT OF MEDICAL NECESSITY
PHYSICIAN INFORMATION
Please read and acknowledge statements below.
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I certify that am the treating provider identified below and confirm that the patient's diabetic condition warrants the need for a Continuous Glucose Monitoring System and/ or Insulin Pump that meets Medicare's Criteria for coverage.
I certify that the above patient will be treated under a comprehensive care plan for patient's diabetes mellitus and that patient has been seen 6 months prior to order request
I agree to comply with submission of clinical notes that supports patient's continued use of the CGMS and/ or Insulin Pump every 6 months and adherence to the diabetes treatment plan.
Signature
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Date
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Month
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Day
Year
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PHYSICIAN NAME
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NPI
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OFFICE ADDRESS
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE
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Phone number with area code
FAX#
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CONTACT PERSON
*
UPLOAD CLINICAL NOTES BELOW
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Should you have any issues, questions, or require an accommodation to be able to submit this form, please contact us at (808) 840-5681 or email rmann@pharmacarehawaii.com for assistance.
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