Indiana Incontinence Form

Who is completing this form?*
- Caregiver First Name*
- Caregiver Last Name*
Patient Contact Information
First Name*
Last Name*
Phone Number*
Medicaid Number*
Email*
Date of Birth*
Address
Apt
City
State
ZIP
Primary Doctor Name
Select Product
Best time to reach you?
Questions / Comments
Upon completing this enrollment form, you will receive a confirmation email from Binson's. If you did not you will still be contacted by our Member service department. Our Member service department will contact you within 2 business days according to your "Best time to call" choice and other instructions ("Comments" field). You will also receive a follow-up information packet in the mail. Binson's will obtain all necessary prescriptions, authorizations and medical documentation for you.

Don't delay. Enroll now to ensure you won't run out of supplies. If you should have any questions, please call 1-888-217-9610, 8:00am - 5:30pm EST.