1. Insulin Delivery System
Ordering is Simple.
Complete and return the “Patient Information/
1 AOB” form, along with a copy of the front and
back of your insurance card via fax or mail
This 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
2 determine your benefits
We 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
3 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.
If you prefer to mail your forms to us,
please send them to: Have questions? We are here to help.
ATTN: Customer Sales Support
Tandem Diabetes Care Our Customer Sales Support team is available
11045 Roselle St., Monday – Friday, 6:00 AM to 6:00 PM PST
San Diego, CA 92121 Call us at 877-801-6901

2. PATIENT INFORMATION / AOB Tandem Diabetes Care Customer Support
(877) 801-6901
FAX completed signed form to (855) 875-4648
PATIENT’S NAME (FIRST, MIDDLE, LAST) GENDER
 MALE  FEMALE
PATIENT INFORMATION
PATIENT’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  EMAIL
EMERGENCY CONTACT PHONE NUMBER RELATIONSHIP
PRESCRIBING PROVIDER NAME SPECIALTY
PROVIDER INFO
PRESCRIBING
OFFICE STREET ADDRESS PHONE NUMBER
CITY STATE ZIP CODE FAX NUMBER
GROUP PRACTICE NAME OFFICE CONTACT NAME
 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
INSURANCE INFORMATION (CHECK ALL THAT APPLY)
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  GUARDIAN
IF 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  GUARDIAN
IF MEDICARE MEDICARE NUMBER EMPLOYER’S NAME
 PART B
Assignment of Insurance Benefits and Authorization to Release Information
Please 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.
PATIENT/GUARDIAN SIGNATURE DATE (MONTH/DAY/YEAR)
X
© 2012 Tandem Diabetes Care, Inc. All rights reserved. 11045 Roselle Street • San Diego, California 92121 • www.tandemdiabetes.com ADMF-000007_D