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Diabetes Supply Reorder Form

  • Diabetes Supply Reorder Form

  • * - Indicates a required field

  • This can be found on an Invoice or Pick Ticket

  • 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.

  • Patient Status Questionnaire

  • Who is completing this form?
  • Are you currently in a Hospital or Nursing Home?*
  • Have you ordered from another supplier since your last order?*
  • Has your times testing daily changed?*
  • Has your insurance changed?
    • Insurance Information

  • Have you changed physicians?
  • Continuous Glucose Monitor Screening
    • Physician Information

  • Product Information

    Please select the Diabetes products you would like to reorder.

  • Do you need test strips? *
  • Do you need lancets? *
  • Do you need a lancet device? *
  • Do you need control solution? *
  • Do you need a new glucose meter?*
  • 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.

    I WILL CALL THE CUSTOMER SERVICE DEPARTMENT AT 888.246.7667 IF MY USAGE OF MY MONTHLY/QUARTERLY SUPPLIES CHANGE.

  • 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.

  • NOTICE OF COMMUNICATION PRACTICES AND RELEASE REGARDING COMMUNICATIONS:

  • 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

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