Want to Prescribe CGM Online?

1.) Complete the online form below in its entirety (please double check spelling) - when finished completing the online form, DO NOT electronically sign just yet, this will be done in Step 2.

2.) BEFORE electronically signing the online form (AdobeSign), at the bottom of the online form, attach the patient's supporting medical documentation/progress notes along with the patient's current full medication list.  After attaching ALL supporting medical documentation, proceed with the electronic signature (AdobeSign).  If you are unable to attach the file(s) online or prefer to send the file(s) via fax, then you may proceed with the electronic signature (AdobeSign) and fax the documentation to: (201) 987-1187

Once the electronically signed online form and the required medical documentation has been received, we will contact the patient to schedule delivery of their CGM device and supplies.

PLEASE NOTE: For a Medicare Part B Beneficiary (patient) to qualify for CGM benefits, the patient must have diabetes mellitus AND; either on a daily insulin regimen (insulin pump or daily injection(s)) OR has a history of more than one level 2 hypoglycemia events OR has a history of one level 3 hypoglycemia event.  

For your reference, a copy of the CMS Physician RX medical necessity guidance letter can be downloaded here:  <Download CMS Dear Physician Letter>