Required Reporting Frequency. Daily Required Reporting Method or Venue: Web-portal File Type: csv De-limiting character: “,” comma with values enclosed by Quotation Marks Subject to compliance with the applicable provisions of HIPAA, the Care Coordination Reports should adhere to the following format & should not-deviate in order from one report to the next: Status Patient Referral MFG Acct # Date Rec. Contact Date Touch Date Comments F/U Date Ship Date Cancel Date Ins Name Phys Name Phys City Phys State Phys Zip Phys Phone Patient Address Patient City Patient State Patient Zip Patient Phone Patient DOB Serial No. Part No. Quantity
Required Reporting Frequency. Daily Required Reporting Method or Venue: Web-portal File Type: csv De-limiting character: “,” comma with values enclosed by Quotation Marks Subject to compliance with the applicable provisions of HIPAA, the Care Coordination Reports should adhere to the following format & should not-deviate in order from one report to the next: Status Patient Referral MFG Acct # Date Rec. Contact Date Touch Date Comments F/U Date Ship Date Cancel Date Ins Name Phys Name Phys City Phys State Phys Zip Phys Phone Xxxxxxx Xxxxxxx Xxxxxxx Xxxx Patient State Patient Zip Patient Phone Patient DOB Serial No. Part No. Quantity
Required Reporting Frequency. Daily Format: .csv (comma-delimited file) Delivery Method: Dexcom controlled secure file transfer protocol site specific to Distributor Dexcom, Inc. Sales Tracings Requirements Field Format Desired State Comments Dexcom drop ship info included Text No Frequency Text Daily Format Text CSV Delivery method Text sftp Customer ID Number Text Unique identifier A unique identifying number for each customer Customer First Name Text Separate field for first Customer Last Name Text Separate field for last Customer Xxxxxx Xxxxxxx Xxxx Xxxxxxxx Xxxxxx Xxxxxxx Customer City Text Customer City Customer State Text Customer State Customer ZIP Code Text Customer ZIP Code 5-character; text so leading zeros are included; no Zip + 4 numbers Customer DOB Text Customer DOB MM/DD/YYYY Customer Phone Text Text Customer Email Text Text Physician First Name Text Separate field for first Physician Last Name Text Separate field for last Physician Xxxxxx Xxxxxxx Xxxx Xxxxxxxxx Xxxxxx Xxxxxxx Physician City Text Physician City Physician State Text Physician State Physician ZIP Code Text Physician ZIP Code 5-character; text so leading zeros are included; no Zip + 4 numbers Physician NPI Text Physician NPI Medical Facility Name Text Medical Facility Name Medical Facility Xxxxxx Xxxxxxx Xxxx Xxxxxxx Xxxxxxxx Xxxxxx Xxxxxxx Medical Facility City Text Medical Facility City Medical Facility State Text Medical Facility State Medical Facility ZIP Code Text Medical Facility ZIP Code Insurance Name Text Insurance Name Item Number Text Item Number Quantity Text Quantity Unit quantity - e.g. 1 box of sensors is '1', and not the number of individual sensors included Benefit Type Text Benefit Type DME or Pharmacy H/W Lot Number H/W Lot Number Where distributor stocks and ships hardware H/W Serial Number H/W Serial Number Where distributor stocks and ships hardware Date of Sale Date of Sale MM/DD/YYYY Shipper Dexcom or distributor name Dexcom or Distributor, where distributor provides tracings including shipments from both locations 5. SCHEDULE 5. Schedule 5 is amended and restated in its entirety as follows: SCHEDULE 5
