New Patient Paperwork

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Patient Information
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Please use a 10 digit phone number
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Please use a 10 digit phone number
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Please use a 10 digit phone number
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Please use a 10 digit phone number
Prescribing Provider Information
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Please use a 10 digit phone number
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Primary Insurance (to ensure proper processing please provide a copy of the front & back of your insurance card)
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Please use a 10 digit phone number
Please use a 10 digit phone number
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Secondary Insurance (to ensure proper processing please provide a copy of the front & back of your insurance card)
Please use a 10 digit phone number
Please use a 10 digit phone number


Documentation Receipt Acknowledgement
I acknowledge that Diabetes Supply/Education Center of the Midlands has made the following documentation available for review: Notice of Privacy Practices, Patient Rights and Responsibilities, DMEPOS Supplier Standards, Company Complaint Procedure, Emergency Preparedness Information and a listing of all available company services. I understand that I can request an additional copy of this information at any time.
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/Diabetes Supply center for any services rendered to myself and/or dependents regardless of my insurance benefits, if any.
I authorize the release of any information necessary, medical or otherwise, to process my medical claims. 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 my care.
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