Freestyle Libre Order Form Pdf
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FREESTYLE LIBRE 2
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This document contains both information and form fields. Use the noridian clinician resource letter (continuous glucose monitors) to confirm coverage criteria and medical necessity documentation requirements are met*. Inside, you’ll fi nd tips for getting the most out of your cgm system to help manage your diabetes. Whether you’re new to using a continuous glucose monitoring system (cgm) or need a refresher, this guide is for you.
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Web instructions complete all fields on this standard written order. Web instructions complete all fields on this standard written order. Fax both this order and the patient’s most recent medical records that demonstrate coverage criteria are met to a dme supplier that provides the freestyle libre 14 day system. Order information recurrent, unexplained, severe, symptomatic (generally blood glucose levels less than 50 mg/dl) hypoglycemia and this hypoglycemia puts the patient.