Erectile Dysfunction - ED | Private Insurance Form

STEP 1
Complete the patient
information on the right.

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

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 insurance deductible and any amount not covered by your insurance. Your insurance 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 Insurance 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 INFORMATION and PRESCRIPTION:

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

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

Other -

PLEASE have your physician sign the printed form.

Private Insurance Application Form