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Diabetes Reorder Form


Use the form below to reorder your diabetic supplies.
If you have any questions please call our Customer Service Department at 1-855-307-2973.

Step #1 Patient Information
Please check your information carefully as you enter it.
Acct# (7-digit number)
First* Last* Name   *  
Address* *  
Apt/Suite
City* / State* / Zip* * * *
Phone* * example: 800-555-1234
Date of Birth* * example: 01/01/1919
Email* * example: user@domain.com
Mailing List Check to receive valuable special offers,
coupons and newsletters from Binson's.

 * DENOTES REQUIRED FIELD 

Joining our mailing list gives Binson's permission to send you e-mails and valuable coupons.

Note: We never sell or give out your e-mail address.

Step #2 Patient Status Questionnaire
In order to better serve your needs for this reorder, and in the future, please answer all of the following.
Current Diagnosis:
Survey:
Who is completing this form?
If a Representative please enter your name.
Are you currently in a Hospital or Nursing Home? yes   no
Have you ordered from another supplier since your last reorder? yes   no
Has your insurance changed? yes   no
Have you visited your physician in the last year? yes   no
Enter date of last physicain visit.
   example: 01/20/2017
Have you changed physicians? yes   no
Name of current doctor?
Has your times testing changed? yes  no
How many days of test strips do you have left?
How many days of lancets do you have left?

* Per Medicare you cannot reorder if you have more than a 10 day supply left.

Step #3 Diabetes Supplies
(Select at least one product) (Select a reorder reason)
Qty HCPCS Description Reorder Number Units Item# Brand Name
A4253 TEST STRIPS
A4259 LANCETS
A4258 LANCET DEVICE
REORDER REASON
A4256 CONTROL SOLUTION
REORDER REASON
E0607 GLUCOSE MONITOR
REORDER REASON

Reorder Special Instructions:


Step #4 Submit Form
Binson's will contact you if there are any issues processing this reorder for the products selected.

NOTE: For your security and to prevent fraud, only confirmed information will be processed.

CLEAR FORM