New Patient Diabetes Supply Enrollment

New Customer Enrollment Form

For new customers not currently receiving diabetes supplies from Binson's

Please note: This form is for new customers only. If you're looking to reorder supplies, visit our reorder supplies page.

Are you a diabetic who needs supplies to test your blood sugar? Binson's Diabetes Testing Supply Enrollment Order Form makes it easy to order the supplies you need, without having to call or wait in line. You can enroll with us today, and we'll ship them right to your door at no cost. Our knowledgeable staff is available to answer any questions you might have about our products.

Here's How It Works

Step 1

Fill out our online form below.

Step 2

We verify your insurance and prescription.

Step 3

We'll send your order - FREE.

Please complete the form to receive uninterrupted, timely delivery for your home health products. 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 .

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Call (888) 246.7667 ext. 4749 today!

New Patient Diabetes Supply Enrollment

Diabetes Testing 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
Patient Status Questionnaire
Are you being treated with insulin?* Yes No
How may times do you test daily?*
How many days of test strips do you have left?*
How many days of lancets do you have left?*
Continuous Glucose Monitor Screening Are you now or have you ever been on a CGM (Continuous Glucose Monitor)?* Yes No
What meter do you currently use?*
- Send me a new meter*
- Please choose a meter.*
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).

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.

New Patient Diabetes Supply Enrollment

New Customer Enrollment Form

Here's How It Works

Step 1

Step 2

Step 3

Diabetes Testing Supply Enrollment

Insurance Information

Physician Information

Patient Status Questionnaire

Upload an RX