CGM New Patient Intake Form
Interested In Our CGM Services?
Please fill out this form as accurately as possible,
We will get back to you within 24-48 hours.
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Patient Name: 

(As spelled on your Medicare ID)
*
Patient Phone Number:
*
Patient Address:
*
Patient DOB:

(MM/DD/YYYY)
*
Email Address:
How many times are you prescribed to prick your fingers?
Are you currently taking insulin? 

(MUST BE YES)
Have you been supplied a Freestyle Libre or Dexcom monitor in the last five years that was covered by your Medicare?

(If YES we can still possibly fill your sensors).
*
And have you seen your doctor in the last 6 months? 
(MUST BE YES)

If No, you must make doctor appointment for a check up but we will still go ahead and get the process started.
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Do you currently reside in a nursing home or acute care facility? (MUST BE NO)
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Medicare Insurance ID:
*
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Supplemental Insurance Name and ID Number:

(MEDICARE ADVANTAGE OR NJ/NY HMO/PPO)
Physician Name:

(MUST be the primary doctor that manages your diabetic care).
*
Physician Address:

(Street, City, State, Zip)
*
Primary Physician Telephone: *
DO WE HAVE YOUR CONSENT TO SPEAK WITH YOUR DOCTOR TO CONFIRM AND APPROVE THE INFORMATION IN THIS ORDER? *
Required
WE NEED TO MAKE YOU AWARE THESE SUPPLIES ARE COVERED BY TRADITIONAL MEDICARE.  THEY MIGHT NOT COVERED BY MEDICARE ADVANTAGE, LIKE AN HMO OR PPO.

IF YOU DO CHANGE YOU MUST INFORM US 30 DAYS PRIOR TO CHANGING SO WE CAN CANCEL DELIVERY OF YOUR SUPPLIES. IF NOT, YOU CAN BE HELD LIABLE FOR THE COST OF THE SUPPLIES THAT WEREN'T COVERED. 

DO YOU UNDERSTAND THIS STATEMENT?
*
Required
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