PAP Enrollment Form

Please fill out this PAP enrollment form to receive uninterrupted timely delivery of your PAP supplies.
The more information you provide, the easier it is to process your enrollment. The required fields are listed with a red asterisk (*).
If you have any questions please call our Customer Service Department at 1-888-246-7667.

Patient Information

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Submit the above information to receive
a phone call to complete your enrollment
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By filling out and submitting this application you are stating the following:
I have read and understand Binson's Terms & Conditions and the Privacy Policy.
I am giving Binson's Hospital Supplies permission to contact me.
I certify that the information provided on this application is accurate.

Binson's Hospital Supplies is dedicated to protecting your medical information.
We are required by law to maintain the privacy of protected health information.