I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance, and any other health/medical plan, to issue payment directly to
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Assignment of Medicare Benefits I request that payment of authorized Medicare benefits be made on my behalf to Dexcom for any continuous glucose
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MEDICARE NUMBER (This form is the approved form as prescribed I assign /offer to assign my right to benefits to the practitioner who has rendered the
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I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance, and any other health/medical plan, to issue payment directly to
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If other health insurance is indicated in Item 9 of the CMS 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the
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Centers for Medicare and Medicaid Services and its intermediaries of the original and request payment of medical insurance benefits to the party who accepts I have had an opportunity to review this information before signing this form
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Items 14 - 33 · Photocopies of the CMS-1500 claim form are NOT acceptable agreement with Medicare to accept assignment of Medicare benefits for all
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