Forms

 If you have insurance coverage and plan to submit your pump and/or related supplies costs to your insurance, the  Insurance Data Form lets us know your insurance coverage and begin to work with your insurance provider to determine your coverage for insulin pump and related supplies. In some cases, we are able to negotiate better coverage for you as a preferred provider with your health insurance. In other cases, we may need to inform your insurance company on insulin pump therapy and related insulin pump supplies. Click here to download a printable version of the IDF, then simply fill out and follow the directions for returning it to Disetronic.

The Consent Form allows Disetronic to provide products, services and information to you. With your permission, it also allows Disetronic to release specific information about you in order to obtain payment from your insurance company, if applicable. Finally, the consent form serves as a acknowledgement of your receipt of the Disetronic Medical Systems Privacy Statement Canada. Click here to download a printable version of the Consent Form, then simply fill out and follow the directions for returning it to Disetronic.

The Certificate of Medical Necessity Form is signed by your doctor and certifies that you meet basic prerequisites for insulin pump therapy. Examples of these prerequisites include a demonstrated ability to self-monitor your blood glucose, motivation to acheive and maintain improved glycemic control, and that you or your caregiver are physically and intellectually capable of operating an insulin pump. The CMN also specifies the physiological indications for pump therapy, and serves as a prescription for the pump and related supplies. Click here to download a printable version of the Certificate of Medical Necessity Form.

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