Refer a Patient

Dexcom CGM - Clinician Referrals

Thank you for submitting your patient to Dexcom using the clinician portal. You have chosen the fastest and easiest way for your patients to get started in their process to obtain a Dexcom CGM System. A few tips to help us get started:

  1. Please provide as much information as time allows, but at a minimum please provide information in the fields below that are asterisked.
  2. The patients you submit to us using this portal will be prioritized, and will be contacted inside of 24 hours for prompt service.

All fields marked with an asterisk (*) are required. Once you're finished, click "Submit."
All the information you provide is sent securely.

Patient Information
E.g., 02/22/2019
Diabetes Therapy
Provider Information
Patient Insurance
E.g., 02/22/2019
Attachments

Please attach the following forms and documentation:

  1. Chart notes from the last six months (highly recommended)
  2. Commercial Certificate of Medical Necessity (CMN) Download Commercial CMN Form
  3. Medicare Certificate of Medical Necessity (CMN)* Download Medicare CMN Form
  4. Medicare Assignment of Benefits (AOB)* Download Medicare AOB Form

*Required documentation for prescribing CGM to Medicare patients

Examples of other files to attach (up to 10 files):

  • Prescribing Acknowledgement of Benefits
  • Patient Face Sheet
  • Charts
  • Blood Glucose Logs with 30 Days of Data
  • Insurance Cards: Front/Back

By submitting this form, you are representing that you are treating the patient named above and you have prescribed a Dexcom continuous glucose monitoring (CGM) system for use by that patient. We will maintain the patient information you have provided in accordance with our Terms of Use and Privacy Policy, including the requirements of the Health Insurance Portability and Accountability Act.

Contact Dexcom

If you are a clinician and want to learn more about Dexcom’s Continuous Glucose Monitoring Systems, please fill out the form and a Dexcom representative will contact you.

If you are a Dexcom User or Patient, please contact Dexcom here.

The information you provide will be sent securely and subject to the Dexcom Terms of Use and Privacy Policy.