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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 and reviewing all past, present and future medical claims on my behalf, including deductible amounts. 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
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
you agree to the terms of those policies.
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