Standard Written Order

Patient Name:

Date of Birth:

Phone:

Email:

Address:

City, State, Zip:

Primary Insurance:

Primary Insurance Member ID:

Secondary Insurance:

Secondary Insurance Member ID:

Notes:

Please Specify Diagnosis Code:

Is the patient already using a CGM system?

Yes No

Has the patient been seen within the last 6 months?

Yes No

Does the patient's insulin treatment regimen require adjustments based on CGM results?

Yes No Not Applicable

Select the following documented reasons for prescribing CGM to improve beneficiary's glycemic control:

Insulin-treated

3+ insulin administrations per day, or

insulin pump

Multiple Level 2 Hypoglycemic events below 54 mg/dl

Documented Level 3 Hypoglycemic event requiring hospitalization

Order Detail:

Duration of need: LIFETIME (99) - unless specified otherwise:

Please Specify Other:

Patient must use products per manufacturer guidelines, in accordance with FDA indications for use.

Change FreeStyle Libre Sensor every 14 days.

Dispense six sensors/84 days, or seven sensors/98 days.

Patient must use products per manufacturer guidelines, in accordance with FDA indications for use.

Change FreeStyle Libre 2 Plus Sensor every 15 days.

Dispense six sensors/90 days.

Patient must use products per manufacturer guidelines, in accordance with FDA indications for use.

Change Dexcom Sensor every 10 days.

Dispense nine sensors/90 days.

DISPENSE AS WRITTEN

The beneficiary (or beneficiary's caregiver) has sufficient training on the proper use of the products prescribed on this order.

I certify that I am the physician identified in the "Physician Information" section below and hereby attest that the medical necessity information is true, accurate, and complete to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.

Signature (or typewritten name in lieu of signature)

Date

Physician Information

Physician Name

Phone:

NPI:

Fax:

Address:

City, State, Zip:

Office Contact:

Notes:

Please submit updated chart notes from the most recent office visit documenting relevant diagnosis codes and the patient's need for Continuous Glucose Monitoring (CGM). Files can be uploaded below, or faxed to 1-877-228-1780 or emailed to info@WellCareDME.com

Please Upload Chart Notes from Recent Office Visit & other Pertinent Documents Here.

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Standard Written Order

DISPENSE AS WRITTEN

WellCare DME