• Basic Home Blood Glucose Monitor and Supplies Order

    Patient information

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

  • Patient diagnosis

  • Device order

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


  • Supply order: Diabetic Test Strips (DTS) / lancets

  • 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

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