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Easy GlucoseMonitoring

Standard Written Order

Continuous Glucose Monitor (CGM) and supplies

Send the signed order to
Easy Glucose Monitoring
support@easyglucosemonitor.com
Phone (713) 949-2900

1. Patient

Patient full name

Date of birth

Phone

Insurance and member ID (Medicare, Medicaid, private)

Address

2. Diagnosis

Primary diagnosis (ICD-10), e.g. E10.9 type 1, E11.9 type 2

Additional diagnosis codes

Patient has diabetes mellitus and is treated with insulin

Patient has diabetes mellitus and a history of problematic hypoglycemia (level 2 or level 3 events, or recurrent level 1 events despite treatment changes)

Patient (or caregiver) has been trained on the device and the treatment plan will be adjusted based on CGM results

Patient was seen in person or by telehealth within the last 6 months to evaluate diabetes control

3. Item ordered

Dexcom G7 sensors (10-day)

Dexcom G7 sensors (15-day)

Dexcom G6 sensors and transmitter

Dexcom receiver

FreeStyle Libre 3 Plus sensors (15-day)

FreeStyle Libre 2 Plus sensors (15-day)

FreeStyle Libre reader

Other: ______________________________

HCPCS (e.g. A4239 supply allowance, E2103 receiver)

Quantity and frequency (e.g. 3 sensors per 30 days)

Length of need (months; 99 = lifetime)

Instructions (e.g. use continuously; replace sensor per manufacturer instructions; check glucose as directed)

Refills

Order date

4. Treating practitioner

Practitioner name and credentials

NPI

Practice name

Practice phone and fax

Practice address

Practitioner signature (handwritten or valid electronic signature)

Date signed

By signing, the practitioner certifies that the item is medically necessary and that the patient is under their care for the diagnosis listed above.

Easy Glucose Monitoring is an independent supplier and matching service, not affiliated with Medicare, Medicaid, CMS, or any insurance carrier. Coverage criteria vary by payer and change over time; this form is a convenience template and does not replace the payer's own documentation requirements. Dexcom and FreeStyle Libre are trademarks of their respective owners.