CGM REPLACEMENT ATTESTATION

Your Damaged, Lost, or Stolen CGM device.

To allow us to assist you with replacing your damaged, lost, or stolen CGM receiver or monitor, we are required to collect an attestation from you that documents the incident. Please complete the following document.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Phone *

Email *

Please identify your situation: *

Irreparable damage due to a specific incident (example: fire, flood)
Lost
Stolen

Please provide an explanation of the above situation: *

Attestation 1 *

I hereby attest that my CGM Receiver/Monitor is no longer functional and needs to be replaced for me to continue to use my Continuous Glucose Monitoring supplies due to the circumstance listed above.

Attestation 2 *

I also hereby attest that this information is true, accurate and complete to the best of my knowledge and I will provide any confirming details of the incident such as a police report or insurance claim if one was obtained. I understand this document serves as support for coverage but not a guarantee of coverage that my CGM Receiver/Monitor replacement will be reimbursed my insurance company.

Having issues with this process?

Contact our Customer Service Team at:

1-866-241-6885

HOURS OF OPERATION

Monday-Friday: 8:30 am – 5:30 pm
Saturday: Closed
Sunday: Closed

CGM REPLACEMENT ATTESTATION

Your Damaged, Lost, or Stolen CGM device.

Having issues with this process?

Contact our Customer Service Team at:

HOURS OF OPERATION

Call Us Today 1-866-241-6885

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