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Primary Insurance Information (please provide a copy of the front and back of your insurance card).
Please upload an image(s) of the front and back of your insurance card (.jpg, .jpeg, .gif, .png, .tif, .doc, .docx and .pdf accepted - max file size 2MB)
Please be aware that all medical information is confidential under certain state and federal
laws. Such information may not be released without your consent. Many insurance carriers
require medical information to be submitted with claims to evaluate medical necessity. Please
provide your written consent to release related information when required or requested to
your insurance company(s) and/or your healthcare team.
I hereby authorize Tandem Diabetes Care to acquire from and/or release to my healthcare
team, and/or my insurance company(s), and/or contracted distributors any information
required for the purposes of healthcare management and/or for processing all past, present
and future medical claims on my behalf. I understand that upon acceptance of products from
Tandem Diabetes Care, I assume responsibility for any deductible, co-pay, or other balance not
covered by my insurance carrier. I authorize Tandem Diabetes Care to submit claims to my
insurance company on my behalf, and my insurance company to pay benefits directly to
Tandem Diabetes Care. Should any insurance payment be made directly to the insured for
monies due on this account, I agree to immediately pay over these funds to Tandem Diabetes
Care. I will be informed of my insurance coverage and estimated out-of-pocket expense prior to
any shipment of product or any bills being sent. I will notify Tandem Diabetes Care in the event
my insurance changes. This authorization will remain in effect until I revoke it in writing. I
acknowledge that I have received a copy of the Notice of Privacy Practices for Tandem Diabetes
understand, and agree to the attached HIPAA Authorization for Using and Disclosing Protected
Health Information. If the recipient of the Tandem product is a minor, then you represent that
you are the minor’s guardian and you are signing on their behalf and that this signature also
releases Tandem Customer Support to assist the minor or caretaker to provide product support
at no additional charge for Tandem product and services. I further acknowledge that Tandem
has various policies posted on Tandem’s website (including Patient’s Rights Policy and Privacy
Policy) and that you agree to the terms of those policies.
HIPAA Authorization for Using and Disclosing Protected Health Information view
Patient Bill of Rights view