TRICARE East requires approval for an initial continuous glucose monitoring system (CGMS) and for replacement receivers, and Humana Military collects the clinical facts on this one-page attestation. The ordering provider answers five yes-or-no questions on diagnosis, insulin regimen, diabetes education, a recent in-person evaluation and receiver failure, then attaches the form to the online request.
The ordering provider completes and signs the whole form: beneficiary and sponsor ID, provider point of contact, ordering provider name, title and NPI, the request type, five attestation questions and the brand of device requested.
Download the current version from the source each time; forms change without notice.
Continuous Glucose Monitoring System (CGMS) attestation form
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 and their requirements change without notice, so check the official page for the current version before you complete one.
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Not for replenishing transmitters and sensors that Humana Military has already authorized. Approval is required only for the initial continuous glucose monitoring system and for replacement receivers, and this attestation must be attached to those online requests.
Five yes-or-no questions: a diabetes diagnosis (type 1, type 2, gestational or other rare form), daily insulin injections or pump therapy, completion of a comprehensive diabetes education program including device training, an in-person evaluation within six months, and, for replacement receivers, malfunction outside warranty. The provider also names the device brand.
Yes. The request is subject to routine audit by Humana Military or its designee, which may include a request for medical documentation to verify the accuracy of the information, so the chart should support each answer the ordering provider signs.