Walgreens cmn form for diabetic supplies pdf 2026

1. Click ‘Get Form’ to open the walgreens cmn form for diabetic supplies PDF in the editor.
2. Begin with Section A by entering the Certification Type and Date. Specify if this is an Initial, Revised, or Recertification request.
3. Fill in the Patient's Name, Address, Telephone number, and HIC Number. Ensure accuracy as this information is crucial for processing.
4. Provide Supplier Information including your company name, address, telephone number, and NSC Number.
5. In Section B, indicate the Estimated Length of Need in months and list any Diagnosis Codes (ICD-9) relevant to the patient's condition.
6. Answer Questions 1-10 carefully by circling Y for Yes, N for No, or D for Does Not Apply based on the patient's medical history.
7. Complete Section C with a narrative description of equipment needed along with costs. This section should be filled out by the supplier.
8. Finally, ensure that Section D is signed and dated by the physician to certify that all information provided is accurate and complete.

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