Provider Refill – FiggHealth – The Most Innovative In Diabetes Management

Basic Home Blood Glucose Monitor and Supplies Order

Patient information

Last Name*

First Name*

MI

Date of Birth*

Gender*

Other Medical ID

Provider (physician/allowed NPP) who performed the face-to-face examination

Ordering provider:

Check here if same as ordering provider

Last Name*

First Name*

MI

Suffix

NPI*

Date of face-to-face encounter*

Patient diagnosis

Diabetes Mellitus ICD-10 code/ description*

Device order

Device

FiggHealth Smart Glucometer

Patient or caregiver has, or will be provided, sufficient training to use the home blood glucose monitor Ordered above*

Yes
No

Frequency of use for Diabetic Test Strips (DTS) and lancets

Non-insulin treated

1x a day
Up to 3x daily
> 3x daily

Insulin treated

1x a day
Up to 3x daily
> 3x daily

Time of testing*

Fasting,
Before meals
Before Bedtime

Other

Supply order: Diabetic Test Strips (DTS) / lancets

30-day supply (30)
90-day supply (100)
Additional qty
30-day supply (100)
90-day supply (300)
Additional qty

Other

Note: Additional quantities in multiples of 30 or 100 must be justified above and supported by the medical record

Physician or allowed NPP signature, name, order date and NPI

Name as signature*

Date*

NPI*

Phone number*

Email*

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Basic Home Blood Glucose Monitor and Supplies Order

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