Emergency/Alternate Contact Numbers
- I hereby authorize Diabetes Care Center to provide medical care that is deemed necessary. I hereby authorize payment of benefits directly to Diabetes Care Center. I hereby authorize Diabetes Care Center to release any information necessary to process my claims. I acknowledge/understand that I am responsible for any charges incurred that my insurance does not pay for or cover for any reason whatsoever. I also acknowledge that if my account is turned over to a collection agency that I will be responsible for the collection fee towards my account. I also attest that the information that I have provided above is correct and truthful to the best of my knowledge.