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Indiana Incontinence and Ostomy

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First Name*  
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example: 800-555-1234
 
Medicaid ID*
12 digit number
 

Email*  
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Best time to call 9a-12p
12p-3p
3p-6p
   
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from Binson's.
 
CLEAR FORM
 

Upon completing this enrollment form, you will receive a confirmation email from Binson's. If you did not provide an email address you will still be contacted by our Member service department.

Our Member service department will contact you within 2 business days according to your "Best time to call" choice and other instructions ("Comments" field). At that time, we will:

  • Help you select all the products you need
  • Choose a monthly shipment date
  • Perform a brief nursing assessment
  • Answer any questions you may have

You will also receive a follow-up information packet in the mail. Binson's will obtain all necessary prescriptions, authorizations and medical documentation for you.
Don't delay. Enroll now to ensure you won't run out of supplies.
If you should have any questions, please call 1-888-217-9610, 8:00am - 5:30pm EST.

 
 * DENOTES REQUIRED FIELD 
 
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Note: We never sell or give out your e-mail address.