ATTENTION:

Edgepark will be closed Tuesday July 4th in observance of Independence Day.

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Required Forms & Instructions for Downloading

Edgepark strives to take the hassle out of ordering medical supplies. We try to handle as much of the paperwork as possible for our customers.

To process your order, however, and to meet the requirements of your health insurance provider, we may need you to complete one or more of the following forms.

*Click on the form name to start downloading the document.
 

The most common forms we may request from you, your doctor or individuals with a Linked Account:
 

Patient Authorization Form

Allows Edgepark to discuss your order with the necessary parties, such as your doctor and health insurance provider, and gives us permission to bill your health insurance provider for your supplies.
 

Advance Beneficiary Notice (ABN)*

  • For Medicare customers, to confirm that you want to order an item not covered by Medicare by paying out-of-pocket.
     
  • To confirm that you wish to order supplies that may not be reimbursable through Medicare and you acknowledge that you are responsible for paying these out-of-pocket costs.
     
  • To verify that you want to order supplies other than those provided by your home health nurse or other health care professional, and that you will be paying out-of-pocket for those supplies.

*This form is not available for download. It will be provided to you by a Customer Care Specialist, if necessary.
 

Physician’s Written Order (PWO)*

To confirm your doctor’s prescription. Edgepark will work with your doctor to obtain the PWO. In some cases, the doctor may request that the patient bring in the blank PWO for him or her to fill out and submit.

*This form is not available for download. It will be provided to you by a Customer Care Specialist, if necessary.

Logbook

For people with diabetes, this form is a helpful tool for reporting your blood glucose levels – Edgepark and some health insurance providers require this document to confirm that you are complying with your doctor’s prescribed treatment plan.


Marketing Consent Form

Fill out your consent form today to make sure you receive product samples and other important information about your supplies. 
 

Diabetes Device Trade-in Forms**

Eligible customers may receive a trade-in credit for their old devices to use towards the purchase of their new device.  If you have questions about the trade-in programs available, please contact a Diabetes Device Specialist today.

Animas Trade-in Declaration Form
Insulin Pump Trade-in Acknowledgement Form


United Healthcare Forms (Insulin Pump and CGM)**

We at Edgepark want to make you aware of a very important process change by UHC that will affect how you place your future orders for insulin pumps and supplies (including Omnipod) and/or CGM (continuous glucose monitor) devices and supplies.

Effective July 14th, UHC is now requiring additional documentation be obtained for authorization prior to your order being released for shipment. This new process is as follows:

  1. All necessary documentation is required from your physician.
  2. Once all required documentation is received, authorization will be submitted to UHC for review.
  3. Upon approval of authorization by UHC, your order will ship.


(For reference, we've attached the worksheets which need to be filled out completely by Edgepark for submission to UHC.)

UHC Insulin Pump Request Form      UHC Continuous Glucose Monitoring Form


**These forms may not be uploaded via Edgepark.com.
 

Form download and upload instructions:

  1. Click on the form you need and it should automatically open on your computer.
     
  2. Print the form and fill in all necessary information.
     
  3. Scan the completed form to your computer and save it as a .PNG, JPG, .JPEG, .TIF, .TIFF or .BMP file.
     
  4. Log in to your Edgepark account.
     
  5. On your Account Overview page, select the Document Upload option from the left-hand side of the screen.
     
  6. Follow the onscreen prompts to upload your completed form to Edgepark.