Medicare Assignment of Benefits Form

Required documentation for prescribing CGM to Medicare patients

When prescribing a Dexcom CGM System to a Medicare patient, the Assignment of Benefits form is a necessary part of the document package for Medicare reimbursement. This form is to be signed by the patient or other authorized person.

MEDICARE ASSIGNMENT OF BENEFITS FROM (PDF)

Other documentation required for prescribing CGM to Medicare patients:

Certificate of Medical Necessity (serves as the prescription)
Images of insurance card(s) (front/back)
Chart notes reflecting coverage criteria

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If you are a healthcare provider and want to learn more about Dexcom, please fill out the form and a representative will contact you. If you are a Dexcom User or Patient, please contact Dexcom here.

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Please note: Information provided with the sample request is validated against Provider's license information. To ensure a successful transaction, please confirm your submitted First Name and Last Name match that associated wtih your NPI number.

Do not include prefix (Mr., Mrs., Dr.)

Do not include suffix (MD, Jr., Sr.)

Please use the Provider's NPI

Is your patient on a connected pump device?

Yes

By submitting the above form, I certify that I am a licensed practitioner, authorized to request, receive, and dispense these Samples. I understand that these Samples are being requested for the medical needs of my patients and that I will not sell, resell, barter, return for credit or seek reimbursement for these Samples. I also agree to inform my patients that no claims may be submitted for any Sample Pack. I understand that these Samples include packs containing the Dexcom G6 Continuous Glucose Monitoring System (“Dexcom G6”). Dexcom G6 is FDA cleared for use with a separate piece of durable medical equipment called a receiver. This pack includes one (1) Dexcom G6 sensor and one (1) transmitter and does not include a dedicated receiver. In the event you determine that the Dexcom receiver is medically necessary for your patient during the limited evaluation period, the receiver can be separately purchased from Dexcom. Accordingly, the treating healthcare provider should exercise their clinical judgment, in consideration of the Dexcom G6 Instructions for Use, to only dispense this pack to a patient who (or whose authorized caregiver) (i) has reliable access to a compatible smart device and/or automated insulin delivery system, and (ii) is capable of safely using the products in this pack with their smart device, without the need for a separate dedicated receiver. Please note that if the patient of this pack is a Medicare beneficiary and the individual elects to continue using Dexcom G6 after this sample, the individual will need to obtain a medically necessary Dexcom receiver in order for Medicare coverage to be available. I understand that these Samples will not be provided to any patients that are beneficiaries under the Maine or Colorado state Medicaid programs. I understand that Dexcom will be tracking, and if necessary, reporting and may be subject to disclosure requirements with respect to the provision of these Samples. I acknowledge that the Dexcom G6 cannot be used by multiple patients and agree not to reuse any items included in these Samples. I acknowledge that Dexcom provides no warranties for the Samples other than the warranties outlined in the Instructions for Use. I will comply with all applicable federal, state and local laws in receiving and dispensing these Samples, and I agree to store and use these Samples in a manner consistent with the Dexcom G6 Instructions for Use. Dexcom is a registered trademark of Dexcom, Inc. in the United States and/or other countries. ©2020 Dexcom, Inc. All rights reserved. LBL019682 Rev001

By choosing to request info, you are granting Dexcom, Inc. permission to process your personal information to send you additional information and promotional communications related to Dexcom products. You may opt-out of these communications at any time. Dexcom respects the privacy and confidentiality of your personal information. The information you provide will be sent securely and subject to the Dexcom Terms of Use and Privacy Policy.

Medicare Assignment of Benefits Form

Required documentation for prescribing CGM to Medicare patients

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