Diabetes Enrollment Form

Please fill out this diabetes enrollment form to receive uninterrupted timely delivery of your diabetic 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 1-855-307-2973.

Patient Information


You selected:

Test Strip Name:
Coding:
Sample Size:
Test Time:
Memory:
Talking Meter:
Alternate Site Testing Approved:
Unique Feature:
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.

There are two ways to proceed


Call Me!
Submit the above information to receive
a phone call to complete your enrollment
OR

Complete Enrollment Online!
Click to enter more information
below to complete your enrollment online
 
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.