Rx Order Information

Complete the order form below and mail or FAX back to BONRO Medical, Inc. Please contact us with any questions at 706-210-4730 or Toll Free at 877-266-7699.

4490 Washington Rd.
Bldg. 100, Suite 16
Evans, GA 30809

Mailing Address:
P.O. Box 1880
Evans, GA 30809

Tel: 706.210.4730
Fax: 706.210.4740
Toll Free: 1.877.BONRO99
Visit: www.bonro.com


PATIENT INFORMATION:

Name: __________________________________________

Address: _________________________________ _______________________

City: _______________________________ State: ___________ Zip: ______________

Country: ___________________________  Birthdate: ______/______/__________

Phone: (_______) _______ - ___________ E-mail: ____________________________


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 #: _________________________
Group #: _______________ Policy Holder's Name: ____________________________________

Secondary Policy: ______________________________ Policy #: _________________________
Group #: _______________ Policy Holder's Name: _____________________________________

Other Insurance Policy: __________________________ Policy #: __________________________
Group #: _______________ Policy Holder's Name: ______________________________________


PHYSICIAN INFORMATION and PRESCRIPTION:

Physician Name: ___________________________ Address:__________________________

City: _____________________________ State: _____________ Zip: __________________

Phone: (_______) _______ - _____________ FAX: (_______) _______ - _____________

Email Address______________________________          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 ___ 952.9 Spinal Cord Injury
___ 443.9 Peripheral Vascular Disease ___ 154.0 Colorectal Cancer
___ 250.00 Non-Insulin Dependent Diabetes Mellitus
___ 250.01 Insulin Dependent Diabetes Mellitus

Other:
_______________________________________________________________________________

Physician Signature: ___________________________________
Date: ______/______/____________
NPI#____________________ (Medicare Required)
U-Pin# ___________________


ASSIGNMENT OF BENEFITS:

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).

PROVIDE COPIES OF ALL INSURANCE CARDS, FRONT & BACK.