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