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. Patient Name* Cardholder Name* Cardholder Billing Address* City* State* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip* Phone* Please use a 10 digit phone number Please Pick One* Auto Charge my CC for orders placedAlways call with my total prior to charging my card Changes to this preference can be made on an order by order basis by informing an intake representative Card Type* VisaMastercardDiscover Credit Card Number* CVV * Exp Date* Cardholder Signature* Date* Previous Finish
