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CGM Supply Enrollment Form

Person at the beach with CGM sensor in their arm

Enroll in our CGM Supply Program

The most convenient way to get your CGM supplies

Begin Enrollment

Explore what we offer.


When it comes to your diabetes, you deserve the best. And when you're looking for CGM supplies, that's exactly what we offer. We make it easy to reorder the supplies you need with just a few clicks, and our free shipping means that you don't have to pay a penny extra.

We also offer personalized service from a family owned company that has been in business since 1953. We understand how important it is for people with diabetes to have access to CGM supplies.

That's why we work hard every day to provide patients like you with the highest quality products at the lowest prices possible.


Step 1

Fill out our online form below.

Step 2

We verify your insurance and prescription.

Step 3

We'll send your order - FREE.


The more information you provide, the easier it is to process your order. If you have any questions, please call our Customer Service Department at (888) 246-7667.

 Insulin Pump Supplies

Shipping Medtronic and Tandem Supplies Right to Your Door

Call (888) 246.7667 ext. 4749 today!

Get The Care You Deserve, Enroll Today!


  • CGM Supply Enrollment

  • * - Indicates a required field

  • This can be found on an Invoice or Pick Ticket

  • Gender
  • By checking this box you approve Binson'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.

  • Insurance Information

  • Physician Information

  • Testing Questionnaire

  • How are you currently testing?
    • Are you on insulin?
  • Upload an RX

  • Accepted File Types: pdf, jpg, peg, png

    Billed charges could be applied to yearly deductibles and/or copays. Binson's will attempt to collect the required documentation and bill the insurance claim. No returns on insurance sales, all other returns in 30 days (restocking fee may apply).

  • Rental Equipment:

  • I agree the rental equipment is the property of Binson's and will be returned in good condition when no longer necessary. Any damage to equipment other than ordinary wear and tear will be my responsibility.


  • Assignment of Benefits (AOB):

  • I acknowledge receipt and understanding of Binson's notice of health information privacy practices which provides a description of how Binson's may use and disclose my health information, patient rights & responsibilities, CMS standards, and important information notification. I give consent to Binson's to use and disclose this information for the purposes of: Treatment, payment of authorized benefits on my behalf, health care operations, obtaining information from any health care provider for proper determination of benefits payable, and releasing to my insurance company necessary information for reimbursement for any product/service provided to me. I request payment of authorized Medicare or other payor benefits be made on my behalf to Binson's for any services rendered by Binson's . I agree and understand that I am responsible for any charges not covered by my insurance. I will notify Binson's of any changes in my insurance coverage.


  • By signing this form below, I give Binson's or its authorized vendors or agents, permission to contact me or persons acting on my behalf by telephone, pre-recorded calls, text messages, calls generated by an automated telephone system or by fax, at any telephone number, including any wireless or cell phone number, that I or any healthcare provider making a referral for me to Binson's provided to Binson's. Contacts may include but are not limited to equipment, supplies, re-orders or renewal supplies, upgrades, optional equipment, or any information concerning treatment, payment or operations. I understand that I am not required to provide this consent to Binson's in order to purchase goods or services from Binson's. Please contact Customer Service at 888.246.7667 to limit customer contact.

  • Disclosures
  • Provide your signature below


Orders submitted online will be delivered to the patient by mail within 10 business days after shipping from our facility. If you have questions regarding your order, email us at

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