Finnegan Health Services

Diabetic Supplies Order Form

Submit referrer, clinic, patient, supply, and medical details for diabetic supply orders.

Section 1: Referrer

Referrer Name

Facility City

Phone #

Section 2: Clinic

Physician's Name

Clinic City

Phone #

NPI #

Section 3: Patient Information

Patient's First Name

Patient's Last Name

Date of Birth

Gender

Male Female

Phone Number

Email Address

Emergency Contact

Emergency Contact Phone Number

Relationship to Patient

Does patient get home health care (Medicare only)?

Yes No

Medicaid #

Medicare #

Insurance Company

Insurance Phone Number

Policy #

Group Number

Does patient need automatic shipping?

Yes No

Section 4: Supplies

Does the patient need a new meter? (PASSE & Commercial Insurance only)

Yes No

Blood Testing Strips

Lancets

Continuous Glucose Monitoring (CGM) (Medicare, PASSE, & Commercial Insurance only)

Patients with Primary Medicaid must go through a pharmacy.

Section 5: Medical Information

ICD-10-CM Diagnosis Code

Is the patient treated by:

Insulin shots Oral meds

Amount, per day, patient checks blood sugar

Refills

Is patient pregnant?

Yes No