CPAP Supply Enrollment Form

CPAP Supply Enrollment

* - Indicates a required field

Binson's Account Number

This can be found on an Invoice or Pick Ticket

How did you hear about us?

First Name*

Last Name*

Street Address*

Address 2

City*

State*

Zip*

Phone Number*

Email*

Date of Birth*

Gender Male Female

Additional Info

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.

Agree*

Insurance Information

Primary Insurance Name

Primary Contract Number

Primary Group Number

Secondary Insurance Name

Secondary Contract Number

Secondary Group Number

Physician Information

Physician's Name

Physician's Phone Number

Upload an RX

Do you have an RX to include?