Tandem Statement of Medical Necessity & Prescription Order

Statement of Medical Necessity and Prescription Order

***Patient Health Information***
This form serves as a prescription & statement of medical necessity for the Tandem insulin pump & related diabetes supplies to be provided by Tandem Diabetes Care or authorized distributors &/or product development partners.
Submission Date

MonthDayYear
PATIENT ORDER INFORMATION
Full Name*
First, Middle, & Last
Date of Birth*

MonthDayYear
Sex*

MaleFemaleDecline to State
Phone Number*
Please enter a valid phone number.
Address*

STREET ADDRESS

Street Address Line 2

CityState / Province

ZIP CODE
Patient Insurance*
Patient Subscriber ID*
Patient SSN# (Last 4 ONLY)*
Order Start Date*

MonthDayYear
Tandem Insulin Pump with Control-IQ Technology*

t:slim X2Tandem Mobi System
CGM Brand and Model (separate prescription required)*

Dexcom G6Dexcom G7FreeStyle Libre 2 PlusSensors-365/365Transmitter-4/365Receiver-1/365N/AOther
Please specify "Other" CGM Brand and Model*
Cartridge & Infusion Set Change Every ___ Days*

3 (qty 30)2.25 (qty 40)2 (qty 50)1 (qty 90)
Infusion Set Type*

Patient PreferenceAutoSoft 90 Infusion SetAutoSoft XC Infusion SetAutoSoft 30 Infusion SetVariSoft Infusion SetTruSteel Infusion SetOther/Specific Product
Please specify "Other" Infusion Set Type*
Specific Infusion Set Type*
ORDER START DATE / PUMP & SUPPLIES
Length of Need*

LifetimeOther
Please specify "Other" Length of Need*
Diagnosis Code(s) (select all that apply)*

E10.9E10.65E10.649E11.9E11.65E11.649Other
Please specify "Other" Diagnosis Code(s)*
Diagnosis Date *

MonthDayYear
Reason for supply change frequency and/or both Steel and Teflon Cannula Sets (check all that apply)

Scar TissueSite SensitivityBody Type and Site Variation NeedsInsulin ResistanceOther
Please specify "Other" reason*
Current Therapy (check all that apply)*

Multiple Daily Injections 3-4 times per day with self-adjustments to insulin doses. (Pump start orders required for insulin start; saline training okay if clinic protocol).Durable Insulin Pump with tubing/infusion sets. Device no longer meets medical needs.Disposable Insulin Delivery Device with patch/pod. Device no longer meets medical needs.
Qualifications and Indications as per Medical Records (check all that apply)

Patient/Caregiver completed a comprehensive diabetes program & is educated in diabetes managementPatient is routine with appointmentsBlood glucose is checked as required or CGM used appropriatelyPatient is pregnant or planning pregnancy
Medical Necessity/Reason for Therapy Replacement Need
Please upload any clinical documentation for the patient

Cancelof
PRESCRIBER INFORMATION
Prescribing Provider Name*
NPI*
Office Address*

OFFICE STREET ADDRESS

Street Address Line 2

CITYSTATE

ZIP CODE
Phone Number*
Please enter a valid phone number.
Fax Number*
Fax Number with area code
Practice Name and Notes*
Prescribing Provider Attestation and Signature/Date
I certify that I am the prescribing provider identified above and have reviewed all of the order information above. Any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that all the medical necessity information is true, accurate, and complete, to the best of my knowledge. The patient's record contains supporting documentation, which substantiates the utilization and medical necessity of the products marked above. I understand the indications for use and associated warnings and precautions of the Tandem Diabetes Care products I have prescribed herein. I understand that any falsification, omission,or concealment of material fact may subject me to civil or criminal liability. A copy of this order will be retained as part of the patient's medical record.

____________________________________________________________________________________________________________

WARNING: Control-IQ technology should not be used by anyone under the age of 6 years old. It should also not be used in patients who require less than 10 units of insulin per day or who weigh less than 55 pounds.

__________________________________________________________________________________________________________________________
Prescribing Provider Signature*

Clear
Signature Date*

MonthDayYear
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.
Should be Empty:

Statement of Medical Necessity and Prescription Order

PATIENT ORDER INFORMATION

ORDER START DATE / PUMP & SUPPLIES

PRESCRIBER INFORMATION

Prescribing Provider Attestation and Signature/Date

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.