By clicking "Next" I am certifying that I am a licensed practitioner under state law, that the above therapy is medically necessary, and that the information provided is accurate to the best of my knowledge. I further acknowledge that I have obtained the above patient's authorization to release the above information as required by applicable privacy laws, including but not limited to, the Health Insurance Portability and Accountability Act ("HIPAA"), 42 U.S.C. § 1320 et seq., as well as such other information that may be required for Novo Nordisk Inc., and agents working on its behalf, to determine my patient's insurance coverage information.