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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IF YOU PREFER, YOU CAN FAX CLINICAL NOTES TO 808-840-4171
FAILURE TO SUBMIT WILL DELAY PROCESSING TIMES
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 smattos@pharmacarehawaii.com for assistance.
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