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Enrollment Form

 
First Name *
 
Last Name *
 
Phone Number *
 
Medicaid Number *
 
Email *

Date of Birth * Example: MM/DD/YYYY
 
Address
 
Apt
 
City
 
State
 
Zip Code
 
Best time to call
 Primary Doctor Name
 Select Product
 
Comments
 
Upon completing this enrollment form, you will receive a confirmation email from Binson's. If you did not provide an email address 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.
* DENOTES REQUIRED FIELD