Credit Card Authorization Form

I , authorize Diabetes Education/Supply Center of the Midlands to charge my credit card for the balance of charges not paid by insurance, any self pay services or orders, and any copay amounts.
I understand that this authorization is effective as of the signature date on this form and I understand that this form is VALID UNLESS I cancel the authorization through written notice to the Diabetes Education and/or Supply Center of the Midlands.
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Please use a 10 digit phone number
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Changes to this preference can be made on an order by order basis by informing an intake representative
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