CGM Enrollment Form

Person at the beach with CGM sensor in their arm

Enroll in our CGM Supply Program

The most convenient way to get your CGM supplies

When it comes to your diabetes, you deserve the best. And when you're looking for CGM supplies, that's exactly what we offer. We make it easy to reorder the supplies you need with just a few clicks, and our free shipping means that you don't have to pay a penny extra.

We also offer personalized service from a family owned company that has been in business since 1953. We understand how important it is for people with diabetes to have access to CGM supplies.

That's why we work hard every day to provide patients like you with the highest quality products at the lowest prices possible.

Step 1

Fill out our online form below.

Step 2

We verify your insurance and prescription.

Step 3

We'll send your order - FREE.

The more information you provide, the easier it is to process your order. If you have any questions, please call our Customer Service Department at (888) 246-7667.

Insulin Pump Supplies

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Call (888) 246.7667 ext. 4749 today!

Get The Care You Deserve, Enroll Today!

CGM Supply Enrollment
* - Indicates a required field
Binson's Account Number
This can be found on an Invoice or Pick Ticket
How did you hear about us?
First Name*
Last Name*
Street Address*
Address 2
City*
State*
Zip*
Home Phone Number
Cell Phone Number*
Opt-In to receive text messages from Binson's. Terms
Email*
Date of Birth
Gender Male Female
Additional Info
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.
Agree*
Insurance Information
Primary Insurance Name
Primary Contract Number
Primary Group Number
Secondary Insurance Name
Secondary Contract Number
Secondary Group Number
Physician Information
Physician's Name
Physician's Phone Number
Testing Questionnaire
How are you currently testing? CGM Traditional
- Are you on insulin? Injection Insulin Pump
- How may times do you inject insulin daily?
- How may times do you test daily?
What CGM machine do you currently use?
Please indicate the CGM machine do you currently use
Upload an RX
Do you have an RX to include? Accepted File Types: pdf, jpg, peg, png
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 I agree to the terms and conditions* I have read and understand my patient rights *
Provide your signature below

Close

How to use the Ink Signature

The Ink Signature box can be used on a desktop computer, tablet or mobile device. For touch screen devices such as a tablet or mobile device simply use your finger or stylus to write your signature. For use on a desktop computer, left-click inside the signature box and hold. While holding move the mouse as a writing tool to write your signature.

Orders submitted online will be delivered to the patient by mail within 10 business days after shipping from our facility. If you have questions regarding your order, email us at contact@binsons.com.

CGM Supply Enrollment Form

Enroll in our CGM Supply Program

Step 1

Step 2

Step 3

CGM Supply Enrollment

Insurance Information

Physician Information

Testing Questionnaire

Upload an RX

Rental Equipment:

Assignment of Benefits (AOB):

NOTICE OF COMMUNICATION PRACTICES AND RELEASE REGARDING COMMUNICATIONS:

How to use the Ink Signature