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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 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
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