Confidential Men’s Putting penis pumps to the test

Transcription

Confidential Men’s Putting penis pumps to the test
Confidential
HOW TO ORDER:
HOW
ORDER:
•We
can help TO
you regain
control of your sexual performance and satisfaction today.
Men’s
•Please provide us with the following information and have your physician fill out
and process the attached form. All information must be complete prior to shipment.
•You can also call a patient support specialist at (888) 503-2481 to assist with any questions.
•Y
•We will help you complete your order form, obtain your prescription and file your Medicare claim.
•If you do not qualify for a reimbursed unit, please visit www.postvac.com for over the counter options.
THE SEX AND HEALTH NEWSLETTER FOR MEN
Patient Information
Patient
Patient Name:Information
________________________________________________________________________________________
Putting penis pumps
to the test
Address: __________________________________ City: _________________________ State:______ Zip: _____________
Phone: ___________________________________ Birth Date:___________ Medicare Policy Number:_______________________
Secondary Insurance Company Name:______________________________________________ Phone:_______________________
Plan/Group #: _______________________________________ Secondary Policy Number: ___________________________________
The Assignment of Benefits
The
Assignment
of Benefits
Patient Signature
Required.: ______________________________________________________
Date: _________________________
I authorize the equipment supplier to file for my insurance benefits for my purchase. If you have Medicare Part B, you only need to fill out the form (completely), and mail/fax it
back in with a copy of your Medicare card (front and back) and a patient support specialist will contact you to process your order.
YYou are responsible for paying Pos-T-Vac the total amount of your unmet Medicare deductible or any amount not covered by insurance. Proof of paid deductible is required.
*You
Y must sign and date the Assignment of Medicare Benefits section (see above).
We cannot bill through an HMO without prior authorization. You
Complete your product selection
TTech M.O.S.your ❑
T B.O.S.
T Advantage $75 upgrade
❑
Erec-Tech
Erec-Tech
Tech
❑ Erec-Tech
Tech
Complete
product
selection
Could regular
pumping form.
Have your physician complete
the prescription
make your
penis
larger,DISPENSEform.
Have
your
physician
complete
prescription
\ Vacuum
Therapy
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Formthe
DO NOT
SUBSTITUTE.
AS WRITTEN
harder
and healthier?
\The patient
Vacuum
Therapy
System
Prescription
Form
indicated
below
has been
diagnosed
with:
❑ 607.84 Organic Impotence
❑ 952.9 Spinal Cord Injury
❑ 188.9 Carcinoma of Bladder
❑ Other
This
erectile
dysfunction
is
a
result
of:
❑ 607.84 Organic Impotence
❑ 952.9 Spinal Cord Injury
❑ 188.9 Carcinoma of Bladder
❑ Other
❑ 185.0 Carcinoma of the Prostate
❑ 250.00 Diabetes Mellitus ❑ 401.9 Hypertension
❑ Yes
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Physician Name: _______________________________________________NPI#____________________________________
Address: __________________________________ City: _________________________ State:______ Zip: _____________
Phone: _____________________________________________________ Fax: ___________________________________
“I pres
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v ccuum thera
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f rm
fo
r ation for
f comple
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t eess and accu
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Physicians Signature:___
_______
___
______
________
_____
_________
_______
________
____
_______
______
_________
______
___________
________
________
___
___
___
____________
____________
____________
___
___
___
___
__Date: ___
_______
______
________
_____
________
______
______
____
____
____
__
Fax or Mail all completed information and copies of insurance cards (front & back) with the prescription:
Pos-T-Vac Medical
• 4811 Technology
Drive • Augusta,
GA 30907cards
• Fax: (front
(800) 316-9254
• Postvac.com
Fax or Mail all completed
information
and copies
of insurance
& back)
with the prescription:
Pos-T-Vac Medical • 4811 Technology Drive • Augusta, GA 30907 • Fax: (800) 316-9254 • Postvac.com