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Indiana Incontinence Form

  • Patient Contact Information

  • 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.
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