By submitting the above form, I certify that I am a licensed practitioner, authorized to receive and dispense samples of the Dexcom G7 and G7 15 Day Continuous Glucose Monitoring System and/or the Stelo Glucose Biosensor (the "Samples"). I represent that I am requesting the Samples for evaluation purposes and that I will not (i) sell, resell, barter, return for credit or seek reimbursement for the use of the Samples, or (ii) for professional services for dispensing or evaluating the Samples, I also agree to inform my patients that they should not submit claims for reimbursement to any third party for any Samples.
The Samples are FDA cleared for use with a compatible smart device or separate piece of durable medical equipment called a receiver. Neither devices nor receivers are included in the Samples. Accordingly, and in light of the applicable G7, G7 15 Day, or Stelo Dexcom Instructions for Use, you should dispense Samples only to a patient who (or whose authorized caregiver), in the exercise of your clinical judgment, (i) has reliable access to a compatible smart device and/or automated insulin delivery system, and (ii) is capable of safely using the Samples with their smart device, without the need for a separate dedicated receiver.
Please note that Medicare will reimburse for sensors only if the beneficiary also uses a receiver covered by Medicare. Accordingly, it is appropriate to give Samples to Medicare patients only (in the case of the G7 or G7 15 Day Samples) if they have or would be eligible to obtain (in the case of the G7 or G7 15 Day Samples), a Medicare-covered receiver.
You agree that you will not provide the Samples 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 agree not to reuse any Samples. I acknowledge that Dexcom provides no warranties for the Samples other than the warranties outlined in the applicable Dexcom 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 applicable Dexcom Instructions for Use. Dexcom is a registered trademark of Dexcom, Inc. in the United States and/or other countries. ©2025 Dexcom, Inc. All rights reserved.
