Indiana Incontinence Enrollment Form

Servicing the Great State of Indiana

Incontinence | Ostomy | Urological

Selected by the State of Indiana to serve Medicaid Beneficiaries Statewide.

Who is completing this form?*
- Caregiver First Name*
- Caregiver Last Name*
- Agency/Office Name*
- Office or Title*
- Agency/Office Contact Information Email Phone
- Agency/Office Phone Number*
- Agency/Office Email*
Patient Contact Information
First Name*
Last Name*
Home Phone Number
Cell Phone Number*
Opt-In to receive text messages from Binson's. Terms
Primary Insurance Name*
Primary Contract Number*
Secondary Insurance Name
Secondary Contract Number
State Medicaid Number*
Email*
Date of Birth* Caregiver information required for minors.
- Caregiver First Name*
- Caregiver Last Name*
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.