Medicare Application Form

5 Easy Steps to Complete the Medicare Application
*Once all blocks have been completed please click the button "Continue to the Next Step"
 

STEP 1
Complete the patient
information on the right.

BENEFICIARY INFORMATION:
All fields marked with an * are required.

Beneficiary Name*:
 
Address*:
 
City*:
 
State*:
 
Zip*:
 
Country*:
 
Birthday*:
 
Phone:
 
Email*:
 
How did you hear about us?*:
 
Other:
 

 

STEP 2 
Complete the insurance information and
*Include copies of the front and back of your insurance cards.

INSURANCE INFORMATION:
If you have Medicare or private insurance, we will verify your benefits for you. Your out of pocket cost may be little or nothing. Complete the Patient Information section above, Insurance section below, sign the Assignment of Benefits and have your physician complete the prescription section and mail or fax this form with copies of the back and front of your insurance cards to BONRO Medical, Inc.

Primary Policy:
 
Policy #:
 
Customer Service Phone #::
 
Policy Holder's Name: :
 
     
Secondary Policy::
 
Policy #:
 
Customer Service Phone #:
 
Policy Holder's Name: :
 
     
Other Insurance Policy::
 
Policy #:
 
Customer Service Phone #:
 
Policy Holder's Name: :
 

 

STEP 3

ASSIGNMENT OF BENEFITS:
Patient signature required allowing Bonro Medical to file for insurance benefits. Please sign printed form.

I authorize Bonro Medical, Inc. to file for my insurance benefits for my purchase**.

Patient Signature required: ___________________________ Date:_______________
**You are responsible for paying Bonro Medical, Inc. the total amount of your unmet Medicare deductible or any amount not covered by your insurance. Medicare cannot be through an HMO without prior authorization and you cannot have purchased a VED within the last 5 years.
You must sign and date the Assignment of Medicare Benefits Section (Above).

 

STEP 4

INSURANCE CARDS:
Make copies of FRONT and BACK of insurance cards.

 

STEP 5
Have your physician complete step 5. 
*If you do not have a prescription, please include your physician’s name, address and phone number and we will contact your doctor for you.

PHYSICIAN PRESCRIPTION AND DETAILED WRITTEN ORDER:

Physician Name*:
 
Address*:
 
City*:
 
State*:
 
Zip*:
 
Phone*:
 
Fax*:
 
Email:
 
Specialty*:
 

 

I prescribe a Vacuum Erection Device (CPT/HCPCS Code L7900). It is my expert opinion that a vacuum device is medically necessary to facilitate management of his dysfunction. My patient has been diagnosed with Organic Impotence (Code 607.84) as a result of the following condition(s):

 
185 Carcinoma of the Prostate
401.9 Hypertension
188.9 Carcinoma of the Bladder
443.9 Peripheral Vascular Disease
952.9 Spinal Cord Injury
154.0 Colorectal Cancer
250.00 Non-Insulin Dependent Diabetes Mellitus
250.01 Insulin Dependent Diabetes Mellitus
257.2 Hypogonadism
600.00 BPH w/o Obstruction
600.01 BPH w/ Obstruction
414.00 Coronary Artery Disease
Other -

PLEASE have your physician sign the printed form.