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Diabetes Enrollment Form

  • Diabetes Testing 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

  • Patient Status Questionnaire

  • Are you being treated with insulin?*
  • Continuous Glucose Monitor Screening
  • Upload an RX

  • 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).

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