Auto Fill Authorization Form

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Please use a 10 digit phone number
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(Data/messaging charges may apply)


By signing below, I authorize Diabetes Supply Center of the Midlands (DSCM) to order refills of the following medications and supplies, as prescribed for the patient named above:

I understand this Authorization is valid for up to one (1) year and that I am responsible for notifying DSCM, verbally or in writing, if:

  1. I want to revoke this Authorization.
  2. There are changes in the prescriptions subject to this Authorization, to my insurance coverage, or to the credit card I have given DSCM for automatic payments.
  3. There is any change to the address where refill orders should be shipped.

I understand this Authorization is valid indefinitely and that I am responsible for notifying DSCM, verbally or in writing, if:

  1. I want to revoke this Authorization.
  2. There are changes in the prescriptions subject to this Authorization, to my insurance coverage, or to the credit card I have given DSCM for automatic payments.
  3. I no longer wish to be texted when my order is ready.
I understand and agree that I am to pick up orders within 7 business days, or my order will be voided and returned to stock. I further understand that if my order is voided two times then I will be removed from this program and will need to call in orders as I need them.

I understand that I am financially responsible for all supplies ordered unless I revoke this Authorization, verbally or in writing, 30 DAYS before DSCM places a refill order for a given medication or supply, and that I remain liable for refill orders already placed by DSCM and processed prior to my untimely revocation of this Authorization. Written notice shall be addressed as follows: Diabetes Supply Center of the Midlands, 2910 S. 84th St., Omaha, NE 68124

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You consent and agree that your use of a keypad or other device to type your name in to this form constitutes your signature, acceptance and agreement as if actually signed by you in writing.

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