Insulin Delivery System

If you prefer to mail your forms to us, please send them to:

ATTN: Customer Sales SupportTandem Diabetes Care11045 Roselle St., San Diego, CA 92121

Have questions? We are here to help.

Our Customer Sales Support team is availableMonday – Friday, 6:00 AM to 6:00 PM PST

Call us at 877-801-6901

Complete and return the “Patient Information/AOB” form, along with a copy of the front and back of your insurance card via fax or mailThis form provides us with contact information for you, your healthcare provider, and your insurance company. It also grants Tandem Diabetes Care permission to contact your healthcare provider and insurance company on your behalf. Complete, sign, and fax this form to our confidential fax line at (855) 875-4648, or mail it to the address listed below.

We will work with your insurance company to determine your benefitsWe will contact you to let you know what we find out within two business days of receiving your paperwork. At this time we will walk you through the remaining steps of the process and answer any additional questions you might have.

We will contact your health care provider to obtain a prescription.Once your order is complete, we will confirm the shipping date for your t:slim pump. First orders will start shipping in August 2012.

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Ordering is Simple.

PATI

ENT

INFO

RMAT

ION

PATIENT’S NAME (FIRST, MIDDLE, LAST) GENDER

MALE FEMALEPATIENT’S STREET ADDRESS DATE OF BIRTH (MONTH/DAY/YEAR)

CITY STATE ZIP CODE SOCIAL SECURITY NUMBER

PRIMARY PHONE SECONDARY PHONE TERTIARY PHONE EMAIL

BEST TIME TO CALL OK TO CONTACT YOU AT WORK? PREFERRED METHOD OF CONTACT

MORNING AFTERNOON EVENING YES NO PHONE EMAILEMERGENCY CONTACT PHONE NUMBER RELATIONSHIP

PRES

CRIB

ING

PROV

IDER

INFO

PRESCRIBING PROVIDER NAME SPECIALTY

OFFICE STREET ADDRESS PHONE NUMBER

CITY STATE ZIP CODE FAX NUMBER

GROUP PRACTICE NAME OFFICE CONTACT NAME

INSU

RANC

E IN

FORM

ATIO

N (C

HECK

ALL

THA

T AP

PLY)

PRIMARY INSURANCE INFORMATION (please provide a copy of the front and back of your insurance card) INSURANCE NAME PLAN NUMBER

CLAIMS MAILING STREET ADDRESS PHONE NUMBER

CITY STATE ZIP CODE FAX NUMBER

POLICY NUMBER GROUP NUMBER PLAN TYPE (PPO, HMO, ...ETC.)

POLICY HOLDER’S NAME IF DIFFERENT THAN ABOVE (FIRST, MIDDLE, LAST) POLICY HOLDER’S DATE OF BIRTH

RELATIONSHIP TO PATIENT POLICY HOLDER’S SOCIAL SECURITY NUMBER

SELF SPOUSE PARENT GUARDIANIF MEDICARE MEDICARE NUMBER EMPLOYER’S NAME

PART B

SECONDARY INSURANCE INFORMATION (please provide a copy of the front and back of your insurance card) INSURANCE NAME PLAN NUMBER

CLAIMS MAILING STREET ADDRESS PHONE NUMBER

CITY STATE ZIP CODE FAX NUMBER

POLICY NUMBER GROUP NUMBER PLAN TYPE (PPO, HMO, ...ETC.)

POLICY HOLDER’S NAME IF DIFFERENT THAN ABOVE (FIRST, MIDDLE, LAST) POLICY HOLDER’S DATE OF BIRTH

RELATIONSHIP TO PATIENT POLICY HOLDER’S SOCIAL SECURITY NUMBER

SELF SPOUSE PARENT GUARDIANIF MEDICARE MEDICARE NUMBER EMPLOYER’S NAME

PART B

PATIENT/GUARDIAN SIGNATURE DATE (MONTH/DAY/YEAR)

X

Assignment of Insurance Benefits and Authorization to Release InformationPlease 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 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. 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 Care or have reviewed the privacy policy online at tandemdiabetes.com. I will notify Tandem Diabetes Care in the event my insurance changes. 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. You 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.

Tandem Diabetes Care Customer Support(877) 801-6901

PATIENT INFORMATION / AOB

© 2012 Tandem Diabetes Care, Inc. All rights reserved. 11045 Roselle Street • San Diego, California 92121 • www.tandemdiabetes.com ADMF-000007_D

FAX completed signed form to (855) 875-4648