Recommendation supporting a claim for assisted care or private nursing services.
- Completed by
- Attending physician or nursing service
- Issued by
- Manitoba Blue Cross
- Format
- Fillable PDF
- Language
- English
Manitoba Blue Cross CGM/FGM Special Authorization
Manitoba Blue Cross members use this two-page request to seek coverage for a continuous or flash glucose monitoring system. The prescribing physician confirms which system was prescribed, whether the patient has type 1 or type 2 diabetes, and insulin use. Manitoba Blue Cross's clinical team reviews the request, along with any additional information the physician attaches.
Who completes it
The member completes the member, service recipient and coordination of benefits sections and signs the consent; the physician section and physician's statement must be completed by the prescribing physician.
Submitting and payment
- How to submit it
- The form lists email, fax, mail and an in-person drop box at Manitoba Blue Cross in Winnipeg as ways to submit the request.
Good to know
- For type 2 diabetes, the physician must say whether the patient requires insulin, whether they currently take it, and which insulin types and how often.
- Question 1 asks for the make of the system prescribed, and the form covers both continuous (CGM) and flash (FGM) glucose monitors.
- Coordination of benefits questions ask whether another Manitoba Blue Cross plan, another insurer or a government program also provides benefits.
- Manitoba Blue Cross's download page lists it as the 'Glucose monitoring special authorization request form' under specialty claim forms; the printed form is marked 2023-0710.
Get the official form
Download the current version from the source each time; forms change without notice.
Continuous Glucose Monitor (CGM) / Flash Glucose Monitor (FGM) Special Authorization Request
Fill it with Vero
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.
How this list is checked
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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Frequently asked questions
Who completes the Manitoba Blue Cross CGM/FGM form?
The member fills in the member and service recipient details and coordination of benefits, then signs the consent and authorization. The physician section, which the form says must be completed by the prescribing physician, covers the system prescribed, diabetes type and insulin use, followed by the physician's signed statement.
How do I submit a Manitoba Blue Cross glucose monitor request?
The form lists four channels: email to Manitoba Blue Cross pharmacy services, fax, mail, or in person at the Winnipeg office drop box. The physician's clinical questions are on page one, and the physician's statement and the member's consent are on page two.
Does the Manitoba Blue Cross CGM/FGM form cover type 2 diabetes?
The physician confirms either type 1 or type 2 diabetes. For type 2, the form asks whether the patient requires insulin, whether they are currently taking it, and which types and how often. Additional details that could help the clinical team can be written in or attached.