Get Patient Insurance Form - Dexcom

Filing a Patient Insurance Form is an essential step in securing coverage for your Dexcom products. This guide provides a clear walkthrough of each section of the form, ensuring you have a smooth online experience.

Follow the steps to successfully complete your Patient Insurance Form.

1. Click the ‘Get Form’ button to access and open the Patient Insurance Form in your preferred online editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's full name, date of birth, address, contact numbers, and email address. Select the appropriate gender.
3. Proceed to the 'Prescribing Physician' section. Input the physician's name, group practice name, address, and contact information.
4. In the 'Primary Insurance' section, fill out the insurance provider's name, plan type (HMO, PPO, POS), contact phone, and mailing address. Additionally, enter the policy number, employer/group number, and Rx ID, Rx BIN, and Rx group information.
5. Specify the policyholder's name, relationship to the patient, and date of birth. Indicate the effective date of the insurance coverage.
6. If applicable, fill out the 'Secondary Insurance' section with similar details as the primary insurance, including plan type, insurance name, policyholder information, and effective date.
7. Complete the 'Patient/Guardian Signature' section by signing and printing the patient's name. Include the date of signing.
8. Once completed, fax the finished form along with the front and back of your insurance card to Dexcom at the provided fax number.

Complete your Patient Insurance Form online today to expedite your insurance claims process.