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Diabetes Enrollment Form

Please complete the form to receive uninterrupted, timely delivery for your home health products. 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 .

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 contact@binsons.com.

  • 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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