DME ORDER FORM

DME ORDER FORM

DO NOT LEAVE ANY SPACE BLANK
PLEASE SUBMIT CLINICAL NOTES AT THE BOTTOM OF THE FORM

OR

FAX THEM TO # 808-840-4171
Submission Date

MonthDayYear
Patient Information*

FIRST NAMELAST NAME
DOB*
Address*

ADDRESS

Street Address Line 2

CITYState / Province

Postal / Zip Code
Home Phone*
Home Phone with area code
EMAIL
example@example.com
PRIMARY INSURANCE NAME*
PRIMARY INSURANCE ID #*
SECONDARY INSURANCE NAME
SECONDARY INSURANCE ID#
DIAGNOSIS/ICD CODE:*
STATEMENT OF MEDICAL NECESSITY
Currently on CGM therapy?*

YesNo
Currently on Insulin Pump?*

YesNo
Number of Injections per day
Date of last visit (Must be within 6 months of order)*

MonthDayYear
# Self Monitored Blood Glucose (tests/day)
HbA1c
CGMS ORDER

CHOOSE 1 BRAND ONLY
DEXCOM G6 CGMS

A9278 U8 Receiver (Monitor) Sig: Dispense 1; Refill:0: Use per Manufacturer instructions: 1/365daysA9277 U8- Transmitter Sig: Dispense 1; Refill:3: Use 1 transmitter every 90 days; 4/365 DayA9276 U8 Sensors Sig: Dispense 9; Refill:3: Use 1 sensor every 10 days: 365/365 DaysDexcom G7 CGMS*****
FREESTYLE LIBRE 2 CGMS

A9278 KF Receiver (Monitor) Sig: Dispense 1; Refill:0: Use per Manufacturer instructions: 1/365daysA9276 KF Sensors Sig: Dispense 6; Refill:4: Use 1 sensor every 14 days: 365/365 Days
FREESTYLE LIBRE 3 CGMS

A9276 KF Sensors Sig: Dispense 6; Refill:4: Use 1 sensor every 14 days: 365/365 DaysA9278 KF Receiver (Monitor) Sig: Dispense 1; Refill:0 Use per Manufacturer instructions: 1/365 daysOther
INSULIN PUMP ORDER

OMNIPOD BRAND ONLY
OMNIPOD DASH

A9274 CG - PODS - Sig; Dispense 30; Refill: 3; Use 1 pod every 72 hours (3 days); 120/365 daysA9274 CG - PODS - Sig; Dispense 45; Refill: 3; Use 1 pod every 48 hours (2 days); 180/365 days
OMNIPOD 5 G6

A9274 CG - PODS - Sig; Dispense 30; Refill: 3; Use 1 pod every 72 hours (3 days); 120/365 daysA9274 CG - PODS - Sig; Dispense 45; Refill: 3; Use 1 pod every 48 hours (2 days); 180/365 daysOther
OMNIPOD 5 G6 KIT - NEW START ONLY

A9274 CG - KIT - Sig; Dispense 1; Refill: 0; Use 1 pod every 3 days; 10/30 daysA9274 CG - PODS - Sig; Dispense 30; Refill: 3; Use 1 pod every 72 hours (3 days); 120/365 daysA9274 CG - PODS - Sig; Dispense 45; Refill: 3; Use 1 pod every 48 hours (2 days); 120/365 days
THIS DOCUMENT SERVES AS A PRESCRIPTION AND STATEMENT OF MEDICAL NECESSITY.
PHYSICIAN INFORMATION*

I agree to comply with submission of clinical notes that supports patient's continued use of the CGMS and/ or Insulin Pump every year as required by most insurances.I certify that I am the physician identified below and that the medical necessity information contained in this document is true, accurate and complete, to the best of my knowledge.
Signature*

Clear
Date*

MonthDayYear
PHYSICIAN NAME*
NPI*
ADDRESS*
PHONE*
Phone number with area code
FAX#*
CONTACT PERSON
Prior Authorization (PA) is required under most insurances. Would you like the pharmacy to submit PA for patient?*

YES - Please upload clinical notes for PA below or fax them to 808-840-4171NO - The office will do PA; Please fax PA approval to pharmacy
Upload Clinical Notes Below

Cancelof
WE MUST RECEIVE CLINICAL NOTES FOR PATIENT (VIA FILE UPLOAD OR FAX) FOR PA PROCESS TO START

Average review for most insurances is 14 calendar days
COMMENTS?
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.
Should be Empty:

DME ORDER FORM

STATEMENT OF MEDICAL NECESSITY

CGMS ORDER

INSULIN PUMP ORDER

WE MUST RECEIVE CLINICAL NOTES FOR PATIENT (VIA FILE UPLOAD OR FAX) FOR PA PROCESS TO START

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.