Diabetes Supply Reorder Form

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Insulin Pump Supplies

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Diabetes Supply Reorder Form
* - Indicates a required field
Binson's Account Number
This can be found on an Invoice or Order/Proof of Delivery
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*
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*
Patient Status Questionnaire
What is your current diagnosis?*
Who is completing this form?* Patient Authorized Representative
Authorized Representative's Name*
Are you currently in a Hospital or Nursing Home?* Yes No
Have you ordered from another supplier since your last order?* Yes No
Has your times testing daily changed?* Yes No
How many times do you test daily?*
Has your insurance changed? Yes No
- Insurance Information
- Primary Insurance Name*
- Primary Contract Number*
- Primary Group Number
- Secondary Insurance Name
- Secondary Contract Number
- Secondary Group Number
Have you changed physicians? Yes No
Continuous Glucose Monitor Screening Are you now or have you ever been on a CGM (Continuous Glucose Monitor)?* Yes No
- Physician Information
- Physician's Name*
- Physician's Phone Number*
Product Information

Please select the Diabetes products you would like to reorder.
Do you need test strips? * Yes No
- Quantity of Test Strips*
- Select Product*
Do you need lancets? * Yes No
- Quantity of lancets*
- Select Product*
Do you need a lancet device? * Yes No
- Quantity of lancet devices*
- Select Product*
Do you need control solution? * Yes No
- Quantity of control solution*
- Select Product*
Do you need a new glucose meter?* Yes No
- Select Product*
Reorder Special Instructions
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

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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.

Diabetes Supply Reorder Form

Get The Supplies You Need

Diabetes Supply Reorder Form

Patient Status Questionnaire

Insurance Information

Physician Information

Product Information

Rental Equipment:

Assignment of Benefits (AOB):

NOTICE OF COMMUNICATION PRACTICES AND RELEASE REGARDING COMMUNICATIONS:

How to use the Ink Signature