The New Brunswick Insulin Pump Program uses this 2-page form to confirm that a client meets the medical criteria for continuous glucose monitoring sensor coverage. It records the sensor brand and model, recent A1c results, diabetes type and intensive insulin therapy by pump or 3 or more daily injections. The client applies separately online with income documents, and costs are shared by income.
The client's regular diabetes care provider completes Section 3 and signs it with their licence number: a diabetes specialist, GP or NP, or a Certified Diabetes Educator in a diabetes clinic. Sections 1 and 2 hold client details and the sensor requested.
Download the current version from the source each time; forms change without notice.
Confirmation of Medical Eligibility for Glucose Sensor Coverage
Confirmation de l'admissibilité médicale à la couverture des capteurs de glucose
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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The client's regular health care provider who supports their diabetes management: a diabetes specialist, a GP or nurse practitioner, or a Certified Diabetes Educator in a diabetes clinic. They print their name, sign, and add their licence number and the date. When a client also applies for a pump, the same endocrinologist, internist or pediatrician must approve both.
Yes. New Brunswick posts a French version of the medical eligibility form for glucose sensor coverage alongside the fillable English form on the Insulin Pump Program page. Either version is emailed by the provider to the NBIPP business office, and the client's online application is a separate step.
NBIPP processes a file only after it has both the provider's medical eligibility form and the client's online application with all Notices of Assessment. It doesn't confirm receipt, and it notifies clients by letter once a decision is made, which can take up to 30 days, or longer for paper applications.