Lief Therapeutics - Insurance Eligibility Info
Sign in to Google to save your progress. Learn more
Email *
Full Name *
Date of Birth *
MM
/
DD
/
YYYY
State *
Primary Care Provider's Full Name *
Primary Care Provider's Phone Number *
Primary Care Provider's Email Address
Thank you for filling out the form!
A Lief representative will contact your doctor about prescribing you a Lief. Your primary care doctor needs to participate in your data monitoring in order for Lief to be covered by insurance.

In the event your doctor does not wish to monitor your data, you can still access Lief at www.getlief.com/new_order for $99/month and receive 15% off your first month's subscription using code NEWLIEF15.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Lief Therapeutics. Report Abuse