Durable Medical Equipment (DME) Order Form

Durable Medical Equipment (DME) Order Form

***Patient Health Information***
This form serves as a prescription & statement of medical necessity for the DME items ordered below.
Submission Date

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

MonthDayYear
Sex*

MaleFemaleDecline to State
Phone Number*
Please enter a valid phone number.
Patient Email
example@example.com
Address*

STREET ADDRESS

Street Address Line 2

CityState / Province

ZIP CODE
Patient Insurance*
Patient Subscriber ID*
Patient SSN# (Last 4 ONLY)*
Does the patient have a Secondary Insurance?*

YesNo
Patient SECONDARY Insurance*
Does the patient have Medicare?*

Yes, Medicare A OnlyYes, Medicare A & BNo, patient does not have Medicare
Medicare ID#*
Diagnosis Code(s) (select all that apply)*

E10.65E10.9E11.9E11.65Other
Please specify "Other" Diagnosis Code(s)*
Continuous Glucose Monitors (CGMs)
Select ONE (1) CGM below*

Dexcom G6Dexcom G7Freestyle Libre 2 PlusFreestyle Libre 3 Plus
Indicate what you would like to order below for DEXCOM G6 (select all that apply)

A9278 U8 / E2103 – Receiver (Monitor); Sig: Dispense 1; Refill: 0; Use per Manufacturer instructions; 1/365 days (REQ. FOR MEDICARE)A9277 U8 – Transmitter; Sig: Dispense 1; Refill: 3; Use 1 transmitter every 90 days; 4/365 daysA9276 U8 / A4239 – Sensors; Dispense 9 (90 day supply); Refill: 4; Use 1 sensor every 10 days; 365/365 days
Indicate what you would like to order below for DEXCOM G7 (select all that apply)

A9278 U8 / E2103 – Receiver (Monitor); Sig: Dispense 1; Refill: 0; Use per Manufacturer instructions; 1/365 days (REQ. FOR MEDICARE)A9276 / A4239 – Sensors; Sig: Dispense 9 (90 day supply); Refill: 4; Use 1 sensor every 10 days; 365/365 days
Indicate what you would like to order below for FREESTYLE LIBRE 2 PLUS (select all that apply)

A9278 KF / E2103 – Reader (Monitor); Sig: Dispense 1; Refill: 0; Use per Manufacturer instructions; 1/365 days (REQ. FOR MEDICARE)A9276 KF / A4239 – Sensors; Sig: Dispense 6 (90-day supply); Refill 4; Use 1 sensor every 15 days; 365/365 days
Indicate what you would like to order below for FREESTYLE LIBRE 3 PLUS (select all that apply)

A9278 KF / E2103 – Reader (Monitor); Sig: Dispense 1; Refill: 0; Use per Manufacturer instructions; 1/365 days (REQ. FOR MEDICARE)A9276 KF / A4239 – Sensors; Sig: Dispense 6 (90-day supply); Refill 4; Use 1 sensor every 15 days; 365/365 days
Do you need the pharmacy to submit the authorization?*

YesNo
Insulin Pump
Choose ONE (1) Insulin Pump below*

Omnipod Dash 5 G6 Dexcom (NOT COVERED BY MEDICARE B)Omnipod 5 G6 / G7 (NOT COVERED BY MEDICARE B)Omnipod 5 G6 / Freestyle Libre 2+ (NOT COVERED BY MEDICARE B)Beta Bionics iLet PumpTandem t:slim X2 PumpTandem Mobi Pump
Indicate what you would like to order below for OMNIPOD DASH 5 G6 DEXCOM (select all that apply)

A9274 CG – Pods; Sig: Dispense 10; Refill: 11; Use 1 pod every 3 days; 120/365 days
Indicate what you would like to order below for OMNIPOD 5 G6 / G7 (select all that apply)

A9274 CG – Kit; Sig: Dispense 1; Refill 0; Use 1 pod every 3 days; 10/30 daysA9274 CG – Pods; Sig: Dispense 10; Refill 11; Use 1 pod every 3 days; 120/365 days
Indicate what you would like to order below for OMNIPOD 5 G6 / FREESTYLE LIBRE 2+ (select all that apply)

A9274 CG – Kit; Sig: Dispense 1; Refill 0; Use 1 pod every 3 days; 10/30 daysA9274 CG – Pods; Sig: Dispense 10; Refill 11; Use 1 pod every 3 days; 120/365 days
Indicate what you would like to order below for BETA BIONICS iLET PUMP

A4232 / A4225 - iLET Cartridge for Beta Bionics; Sig: Dispense 10 (30-day supply); Refill 11; Use with insulin pump, change every 3 days
Select Infusion for Beta Bionics iLet Pump*

A4230 / A4224 - Inset Infusion (23" x 6MM); Sig: Dispense 10 (30-day supply): Refill 11; Use with insulin pump, change every 3 daysA4231 / A4224 - Contact Infusion (23" x 6MM); Sig: Dispense 10 (30-day supply): Refill 11; Use with insulin pump, change every 3 days
Indicate what you would like to order below for TANDEM t:slim X2 Pump

A4232 / A4225 - t:slim X2 3mL CartridgeA4232 / A4231 / A4224 - Infusion Sets
GHOST - Cartridge&Infusion Set Change days*
Select Infusion Set Type for Tandem t:slim X2 Pump*

AutoSoft 90 Infusion Set (A4230 / A4224)AutoSoft XC Infusion Set (A4230 / A4224)AutoSoft 30 Infusion Set (A4230 / A4224)VariSoft Infusion Set (A4230 / A4224)TruSteel Infusion Set (A4231 / A4224)
GHOST - Tandem t:slim selection*
Specify measurement for Tandem t:slim X2 Infusion Set (e.g., 6mm x 23") *
Indicate what you would like to order below for TANDEM MOBI PUMP

A4232 / A4225 - Tandem Mobi 2ML CartridgeA4230 / A4224 - Autosoft XC Mobi Infusion Set (5" X 6mm)
Cartridge & Infusion Set Change Every ___ Days*

3 (qty 30)2.25 (qty 40)2 (qty 50)1 (qty 90)
Does the patient want the standard 5" X 6mm Infusion Set Type for Tandem Mobi Pump?

Yes, the patient wants the standard 5" X 6mm Infusion Set Type for Tandem Mobi PumpNo, patient has other preference
Patient Preference/Other Infusion Set Type - Tandem Mobi Pump*
Statement of Medical Necessity
Estimated Length of Need (# of months)*
Enter number of months 1- 99 (99 = lifetime)
Currently on CGM Therapy?*

YesNo
Currently on Insulin Pump?*

YesNo
Date of Last Visit (must be within 6 months of order)*

MonthDayYear
Number of INSULIN Injections per day*
Number of SMBG per day*
HbA1c*
CHECK ALL THAT APPLY

The beneficiary treating practitioner has concluded that the beneficiary (or beneficiary’s caregiver) has sufficient training using the CGM prescribed as evidence by providing a prescription
The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least ONE of the criteria below:

The beneficiary is insulin-treated; orThe beneficiary has a history of problematic hypoglycemia
Please mark what documentation of history of hypoglycemia you have on file for beneficiary -

Recurrent (more than one) level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan; orHistory of one level 3 hypoglycemic event (glucose <54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia
Include any additional comments or concerns below (e.g., Sig differs from standard of use or Patient's Preference of Infusion Set, etc.)
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
Contact Name at Provider Office*
Prescribing Provider Attestation
Complete for all DME orders*

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
Complete for MEDICARE DME orders*

I certify that I am the treating provider listed above and 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.
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.
Patient SECONDARY Subscriber ID*
Should be Empty:

Durable Medical Equipment (DME) Order Form

PATIENT INFORMATION

Continuous Glucose Monitors (CGMs)

Insulin Pump

Statement of Medical Necessity

PRESCRIBER INFORMATION

Prescribing Provider Attestation

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.