Patient Information Form

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Please use a 10 digit phone number
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Please use a 10 digit phone number
Please use a 10 digit phone number
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Please use a 10 digit phone number
Complete only if responsible party is not patient
Please use a 10 digit phone number
Please use a 10 digit phone number


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Please use a 10 digit phone number
Insurance Information
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Please use a 10 digit phone number
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If you would like text alerts when your prescriptions are ready for pick up, please fill out the following fields.

PLEASE NOTE: It is extremely important to let the Pharmacy know if you change your mobile number, otherwise the SMS messaging service will not work.

Check which Service you would prefer:

SMS SERVICE CONSENT FORM

I give consent to the Diabetes Supply Center of the Midlands to text me regarding my refill perscriptions.
Please use a 10 digit phone number
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.


Acknowledgement of Privacy Rights
I acknowledge that Diabetes Supply Center of the Midlands/Diabetes Education Center of the Midlands "Notice to Privacy Practices" has been made available for me to review.
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Beneficiary Agreement/Assignment of Benefits
I understand my insurance may deny payment for services rendered. If payment is denied by my insurance, I agree to be personally and fully responsible for payment and any further appeals or reviews concerning my claim. I hereby assign all medical and pharmacy benefits to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s) including, medicare, private insurance and any other health medical or pharmacy plan, to issue payment directly to diabetes education/diabates suppy center for any services rendered to myself and/or dependents regardless of my insurance benefits, if any.
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Authorization to Release Information
Patient or Authorized Person's signature. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. Medical information may also be released to other physicians responsible for your care.
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Correspondence
***Sign below to receive Diabetes Center correspondence***
A quarterly newsletter is published by Diabetes Education Center of the Midlands containing information on diabetes management, recipes, products, and much more. Other information may also be sent.
Disclaimer
By signing up for Diabetes Education and Supply Center of the Midlands materials, you consent to receiving our regular education and communication information, which may include paid advertising. We do not pass on or share your data with any external companies or send any of your information to 3rd party companies. You can unsubscribe at any time by going to our website: www.diabetes-education.com or by calling Patient Services at 402-399-0777.

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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