to communicate at least monthly with a diabetes educator, usually by telephone. I agree to participate in the diabetes education and support process to the best …
Telephonic Diabetes Education and Support Program
MCD/CBA/EBPA
Authorization Statement
Please read the following statement, sign and date where indicated:
I understand that this is a voluntary program
I understand that completion of this application is a condition of
participation
I understand that I can withdraw from the program at any time by
communicating my wishes with the nurse
I understand you will contact my doctor for his/her approval of my
entry into the diabetes program
I understand that my personal information will be kept confidential and
only shared with my diabetes educators and my personal
doctor
I agree to communicate at least monthly with a diabetes educator,
usually by telephone
I agree to participate in the diabetes education and support process to
the best of my ability
I understand that my co-payment for diabetes supplies and medications and
cardiovascular medication will be reduced by half The benefit will start
2- 5 business days following the first meeting with the diabetes educator
This
benefit will continue for a twelve month period if I remain actively
involved in the program by participating in regular phone calls with the
diabetes educator
Initial Here
I hereby authorize Medical Care Development to release my personal
information to participating clinicians and hospitals for the purpose of my
participation in the Telephonic Diabetes Education Program and Support
Program I understand that my eligibility for benefits, processing and
payment of claims, or treatment is not conditioned on giving this
authorization or revocation of this authorization However, if I do not
give this authorization or if I revoke this authorization, I will not be
allowed to participate in the Telephonic Diabetes Education and Support
Program
A copy of this Application and Authorization is available to me, or to my
authorized representative, upon request and will serve as the original I
understand that if this information is to be received by individuals or
organizations that are not health care providers, health care
clearinghouses, or health plans covered by federal privacy regulations, my
information may be re-disclosed by the recipient and no longer protected by
federal privacy
regulations
I have the right to cancel this release of information/authorization at any
time, except to the extent that the person/company has already taken action
on the disclosure provisions contained in this document If I choose to
cancel the release of information/authorization, I must notify Medical Care
Development in writing that I request a cancellation of this release of
information/authorization This Authorization shall remain effective until
revoked in writing by me
___________
Printed Name Signature
Date
Source:mcd.org
