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 do hereby authorize Tandem Diabetes Care to acquire from and/or release to my healthcare team, and/or my public or private insurance provider(s), and/or contracted distributors, and/or product development partners 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 products 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 Notices of Privacy Practices for Tandem Diabetes Care and of the state and federal Medicare, health care fraud, and abuse disclosures or have reviewed those documents online
at tandemdiabetes.com. If the recipient of the Tandem product is a minor, then I represent that I am the minor’s guardian and I am signing on his/her 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 Privacy Policy) and that
I agree to the terms of those policies.
