Dexcom Certificate of Medical Necessity
This file is a Certificate of Medical Necessity for the use of Dexcom Continuous Glucose Monitoring System. It contains patient information, physician information, medical necessity statement, and clinical indications. The document also serves as a prescription for Dexcom devices and supplies.
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How do I fill this out?
To fill out this form, you will need the patient’s and physician’s information, diagnosis codes, and specific details regarding the prescribed Dexcom devices and supplies. Ensure all required fields are completed accurately to avoid delays in processing. Follow the instructions provided in each section of the form.
How to fill out the Dexcom Certificate of Medical Necessity?
1
Gather patient information including name, address, date of birth, and contact details.
2
Collect physician information including name, phone number, fax number, and NPI number.
3
Fill in the diagnosis codes and indicate whether the patient is currently on CGM therapy.
4
Complete the supporting clinical indications section based on the patient's history and current condition.
5
Sign and date the form, then fax it to the provided number or send it to the specified address.
Who needs the Dexcom Certificate of Medical Necessity?
1
Patients diagnosed with diabetes in need of continuous glucose monitoring.
2
Physicians prescribing Dexcom Continuous Glucose Monitoring System to their patients.
3
Diabetes educators assisting patients with complex diabetes management.
4
Healthcare providers seeking to provide necessary medical equipment for diabetic patients.
5
Insurance companies reviewing medical necessity for coverage and reimbursement purposes.
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1
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What are the instructions for submitting this form?
Fax the completed form to 877-633-9266 or mail it to Dexcom, Inc., 6340 Sequence Drive, San Diego, CA 92121. Ensure all fields are correctly filled and signed by the physician to avoid any delays in processing. For questions or additional information, contact Dexcom directly.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates mentioned for the submission of this form in 2024 and 2025.
What is the purpose of this form?
The purpose of this form is to document the medical necessity for a patient to use the Dexcom Continuous Glucose Monitoring System. It serves as a prescription and provides detailed information about the patient's condition and the required devices and supplies. This form is essential to ensure that patients receive the appropriate equipment and coverage for effective diabetes management.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes fields for patient last name, first name, address, zip code, phone number, city, date of birth, state, and patient ID number.
- 2. Physician Information: Includes fields for physician last name, first name, phone number, fax number, NPI number, and diagnosis codes.
- 3. Statement of Medical Necessity: Details about the patient's current therapy, insulin pump usage, HbA1c levels, blood glucose fluctuations, and daily injections.
- 4. Supporting Clinical Indications: Includes history of hypoglycemia unawareness, severe glycemic excursions, severe hypoglycemia episodes, and other related conditions.
- 5. Signature and Date: Fields for the physician’s signature and date to certify the information provided.
What happens if I fail to submit this form?
Failing to submit this form may result in a delay or denial of coverage for the Dexcom Continuous Glucose Monitoring System and related supplies.
- Delayed Processing: Submission delays can impact the timely approval and delivery of necessary medical devices.
- Coverage Denial: Incomplete or unsubmitted forms may lead to insurance coverage denial for glucose monitoring supplies.
How do I know when to use this form?
- 1. Prescription: Used by physicians to prescribe continuous glucose monitoring devices and supplies.
- 2. Medical Necessity Documentation: Provides proof of medical necessity to ensure insurance coverage and reimbursement.
- 3. Patient Information: Captures essential details about the patient’s condition, therapy, and history.
Frequently Asked Question
What is the purpose of this form?
This form serves as a Certificate of Medical Necessity for the Dexcom Continuous Glucose Monitoring System and related supplies.
How do I fill out the patient information?
Enter the patient’s personal details such as name, address, date of birth, and contact information.
What physician details are required?
Provide the physician’s name, phone number, fax number, and NPI number.
Which diagnosis codes should be used?
Use relevant diagnosis codes, such as ICD-10 codes, provided by the physician.
What should be included in the clinical indications section?
Include information on the patient's history and current condition related to diabetes management and glucose monitoring.
How can I edit this form?
Upload the form to PrintFriendly and use our PDF editor tools to make necessary edits.
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Use the signature feature on PrintFriendly to add your signature directly to the PDF.
How do I share the completed form?
Utilize PrintFriendly’s share features to send the document via email or create a shareable link.
Where do I submit the completed form?
Fax the completed form to the provided number or send it to the specified address in the form.
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