For Loving Couples - Encore Patented Vacuum Therapy for Erectile

Order Form
Patient Information
❑ Deluxe Vacuum System
$495.00
❑ Manual Non-Prescription Vacuum Device
$129.95
❑ Battery Non-Prescription Vacuum Device
$169.95
Add $12 for shipping
Total Amount Enclosed
(please do not send cash)
❑ Mastercard
❑ Visa
❑ Discover
❑ American Express
First Name
An Important Message for Men
And The Women Who Love Them:
MI
Month
Day
Year
Medicare #
Review your Medicare card for the following Information:
Does your card indicate medical insurance (Part B)
❑ Yes ❑ No
If yes, you are eligible! Call us if you are unsure or have any
questions.
Medicare is my primary Health Care Plan
❑ Yes ❑ No
I authorize the release of any medical information necessary to
process this claim.
Send Check or Money Order:
Or Charge to My:
Patient’s Last Name
DATE
OF
BIRTH
With your doctor’s prescription, we will take medicare
assignment on the Deluxe vacuum device. We will bill your
secondary insurance, or you, for the required medicare
co-payment.
For Loving Couples
For Medicare claims, complete the following
Signature of patient
Secondary Insurance Information
Credit Card #
Company Name: /
Claims Address: City, State, Zip: Expiration Date
Cust. Service Phone #: Policy #: Signature
Mail Your Order to or Call:
Patient’s Last Name
Encore Inc.
7696 15th Street E.
Sarasota, FL 34243
Tel (800) 475-3091
Fax (941) 359-3509
First Name
MI
Street Address
City
State
Available at
Zip
Encore Inc.
Area Code
Tel (800) 475-3091
Telephone Number
DR
What is Impotence?
Impotence is the inability to achieve and maintain
a satisfactory erection to complete intercourse.
Numerous physical conditions such as prostate
disorder, high blood pressure and diabetes
can cause impotence. Even poor diet, years of
smoking or medications can affect a man’s ability
to achieve or hold an erection.
It is easy to understand why 30 million American
men have erectile dysfunction. The American
Urology Association’s clinical panel on treating
impotence has recommended vacuum therapy as
a safe and effective non-invasive treatment.
How Does The
Encore System Work?
This device will create an immediate strong erection
for 90% of all men regardless of the underlying
cause of the problem. Vacuum therapy creates an
erection by placing the penis in a cylinder which
draws blood into the erectile tissues mimicking the
natural process. The erection can be maintained
by a specially designed ring placed by the patient
around the base of the penis.
Medicare Patients - Vacuum Therapy
is a Covered Benefit!!
Medicare patients who have Medical Insurance,
(Medicare Part B), can receive our Deluxe Vacuum
System by mailing us the following information:
1) Please complete both sides of this brochure.
2) Include your doctor’s prescription or have
your doctor sign below.
PHYSICIAN INFORMATION
(Must be Completed for Patient’s Insurance billing)
Principal Diagnosis
__607.84 Organic Impotence
__Other
If you are a private pay patient, please
consider our over the counter vacuum device.
(No Prescription Required)
ImpoAid™ VTU-1™
Secondary Diagnosis
__250.01 Insulin Dependant Diabetes Mellitus
__250.01 Non-Insulin Dependant Mellitus
__433.90 Peripheral Vascular Disease
__340.00 Multiple Sclerosis
__V15.3 Radiation Therapy
__U12.4 Spinal Cord Injury
__Prostate Surgery
__Implant Prosthesis Removal
__995.20 Medication
__Other
Patient Prognosis
Physician’s Last Name
c Good
ImpoAid™ VTU-E™
c Fair
First Name
c Poor
MI
City
Area Code
NPI Number
State
Zip
Telephone Number
“I prescribe and request Encore Medical Products to ship one
(1) VTU™ Therapy Unit to my patient, listed below, because the
VTU™ System is medically necessary.”
Signature of Physician
Patient’s Last Name
Consists of a battery pump
which will twist into the
penile tube. It comes with
four incrementally different
size rings and comes as
shown. Complete with
instructions.
One
year
warranty.
Medicare Covered Solution! Deluxe Rx System
Street Address
Consists of a manual pump
which will twist into the penile
tube. It comes with four
incrementally different size
rings and comes as shown.
Complete with instructions.
One year warranty.
Date
First Name
MI
Without question it
is the best vacuum
system on the market
and is ideal for patients
who have Medicare.
The battery powered
pump is activated by
simply pushing the “on”
button into position.
This system is extremely easy to operate and is very quiet
and efficient. It also comes with a manual pump which fits
into the same penile tube. This system comes with seven
incrementally different sized rings, zippered carrying case
and video. This system has a lifetime warranty. No other
manufacturer offers a system that compares with the
quality and value of the Encore Deluxe Rx System.