Prescription CGM Devices - VitalWave Medical Supplies

PATIENT INFORMATION

First Name(Required)

MI(Required)

Last Name(Required)

Date Of Birth(Required)

Sex(Required)

Male

Female

Address(Required)

City(Required)

State(Required)

Zip(Required)

Phone(Required)

Email(Required)

MEDICARE / INSURANCE INFORMATION

Primary Insurance Name

Beneficiary ID Number

Group / Plan Number

Secondary Insurance Name

Secondary Ins. Beneficiary ID Number

Secondary Ins. Group / Plan Number

CGM READER / SUPPLIES ORDER

CGM Model(Required)

Other

30 or 90 day supply(Required)

30 day

90 day (if covered by insurance)

Reader and Supplies Ordered unless otherwise indicated

Supplies Only (Pt has Reader)

Orders are billed with bundle code K0553/A4239. For Class II device orders, only the CGM items above will be dispensed as no calibration supplies are needed and covered by Medicare. SENSOR WEAR TIME - Libre 3 and Libre 2 - 14 days, Dexcom G6 and G7 - 10 days

Qualification for CGM - All 3 areas must be completed

1. Diabetes ICD10 Code(s)(Required)

E10.9 Type 1 w/o complication

E11.9 Type 2 w/o complication

E10.65 Type 1 with hyperglycemia

E10.649 Type 1 with hypoglycemia w/o coma

Other

2. Last Office Visit(Required)

3. Patient Is Injecting Insulin

Patient is currently using an Insulin Pump

Patient has experienced a covered hypoglycemic event (must provide medical records)

Patient is using insulin

# of times a day

Physician/NP/PA Name(Required)

NPI(Required)

Physician Address(Required)

City(Required)

State(Required)

Zip(Required)

Phone #(Required)

Fax #(Required)

Attach Files

Please attach patient demographic sheet and clinical notes here.

Drag & drop file(s) here

Accepted file types: jpg, png, pdf, Max. file size: 128 MB, Max. files: 10.

Physician Attestation: I have seen and evaluated this patient in the last six month. I certify the medical necessity of these items for this patient. I certify that the above information is true, accurate, and complete. The patient or caregiver is adequately trained to be able to operate and use the prescribed equipment and supplies.

Providers Signature(Required)

Date(Required)

START DATE(Required)

CGM Order Form

PATIENT INFORMATION

MEDICARE / INSURANCE INFORMATION

CGM READER / SUPPLIES ORDER