Cmn Form Diabetic Supplies Details

Looking for a Walgreens application form? You can print out an application online or pick one up at your local store. The typical Walgreens application process includes a job interview and drug test, so be sure to prepare ahead of time. Get all the information you need on how to apply for a job at Walgreens below.

Here is some information that could be beneficial if you're aiming to determine just how long it will require you to fill out walgreens application form and just how many PDF pages it has.

QuestionAnswer
Form NameWalgreens Application Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswalgreens com cmn, cmn form diabetic supplies, cmn form walgreens, walgreens diabetic detailed written order form

Form Preview Example

Physician Order - Diabetic Form

Fax form with physician's signature & date to 1-866-855-5888 (toll free fax)

 

Required

Start Date:

 

Patient Medicare ID:

Medicaid ID:

(if applicable)

Patient Name:

Address:

City:

State:

Zip:

Phone#:

Gender:

Birth Date:

1Diabetes ICD-9 Diagnosis

Diagnosis Code:

 

 

 

 

 

..

 

 

 

 

Other :

 

.

Diabetic Type:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2Treated with Insulin Injections?

Using Infusion Pump to Administer Insulin?

3HBA1C Count ________________

4Testing Frequency _____________ times/day

Approved Medicare Services:

Meter

Control Solution

Battery for Monitor

5Medicare Utilization Guidelines

_____ Y _____ N

_____ Y _____ N

Number of strips and lancets prescribed for a 90-day period equals 1x day=100 | 2x day=200 | 3x day=300 | 4x day=400 | 5x day=500

Lancet Device

Medicare requires an explanation for testing more frequently than 1x day non-insulin or 3x day insulin treated; therefore, I confirm that I have evaluated this patient within the last six (6) months to assess their diabetes control and have noted below the reason(s) for high testing frequency.

I, the undersigned, certify that the above prescribed supplies/equipment are medically necessary for this patient's well being.

In my opinion, the supplies are both reasonable and necessary to the accepted standards of medical practice in treatment of this patient's condition and are not prescribed as convenience supplies. By signing this form, I am confirming that the above information is accurate.

6Sign/Date and Provide Any Missing Information

Physician Name:

 

 

UPIN:

 

 

NPI:

Address:

 

 

 

 

 

 

 

City:

 

 

State:

 

 

Zip:

Phone:

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician Signature:

 

 

 

Date:

 

 

 

 

 

 

[Original Signature and Date Required]

 

Mail Original Form To: Walgreens Medicare Processing, P.O. BOX 4000 DANVILLE, IL 61834-4000

 

 

Phone: 1-888-281-0590

 

 

 

 

Or Fax Form To:

1-866-855-5888

 

 

 

 

 

 

Store #:

Group #:

 

 

 

PLEASE INITIAL AND DATE ALL CHANGES