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

Example: 01/01/1911

By checking this box you approve Binsons's Medical Equipment & Supplies to use a valid credit card to collect copay and or deductible amounts associated with your order.

If you do not have a valid Credit Card on file, or if we require additional information to complete your order, a Binson's representative will contact you.

Submit the above information to receive a phone call to complete your enrollment
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.