Ruston 318-224-3044 • West Monroe 318-350-6644

New Patient Form

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New Patient Form 2017-12-08T13:27:33-05:00

Please fill out the form below.

  • Responsible Party

  • Insurance Information

  • 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.