Bonro Medical Inc. - We Can Help You Regain Intimacy

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Diabetic Supplies

Incontinence Supplies

For your convenience, we have provided 3 ways to order the Vacurect RX.

You may fill out the online form below, "Submit" it to us and we will contact you by phone for instructions on providing us with your signature, your doctor's signature and copies of your insurance cards.
Click here for a "Printer Friendly" version of the same form. Print the form, fill it out and mail or fax it to us.
You can simply call 1-877-266-7699 and we will help you with the process.

STEP 1: PATIENT INFORMATION
Name:
Address:
City:
State:	Zip:
Phone #
E-Mail:
Birth Date:
STEP 2: INSURANCE INFORMATION
Medicare or Primary Policy #
Secondary Insurance Name:
Policy #
Phone #
Plan/Group #
Note: Please provide copies of all insurance cards, front & back
STEP 3: ASSIGNMENT OF BENEFITS
Upon completion of submitting the order form you will be prompted to download and print the Assignment of Benefits form for you to sign and return to Bonro Medical, Inc., along with a copy of your insurance cards (front and back). Insurance guidelines require that the Medical provider obtain a signed copy of the AOB and insurance cards to store in the patient's record. If you should have any questions upon downloading or submitting the completed AOB to Bonro Medical, Inc., please contact one of our customer representatives, Monday - Friday 9:00am-5:00pm EST, at 877.266.7699.
STEP 4: PROVIDE COPIES OF ALL INSURANCE CARDS, FRONT & BACK

STEP 5: PHYSICIAN INFORMATION & PRESCRIPTION
Name:
Address:
Suite/Office#:
City:
State:	Zip:
Phone #
FAX #
E-Mail:
Specialty:
Patient has been diagnosed with Organic Impotence (Code-607.84) as a result of the following conditions(s): PLEASE CHECK ALL THAT APPLY: 185 Carcinoma of the Prostate 188.9 Carcinoma of the Bladder 443.9 Peripheral Vascular Disease 250.00 Non-Insulin Dependent Diabetes Mellitus 250.01 Insulin Dependent Diabetes Mellitus 401.9 Hypertension 952.9 Spinal Cord Injury 154.0 Colorectal Cancer Other: It is my professional opinion that a Vacuum Erection Device is medically necessary to treat my patient's erectile dysfunction. Physician's Signature: ________________________________________ Date: _____/_____/_____ NPI# _____________________ (Medicare Required) U-Pin# ___________________

For your convenience, we have provided 3 ways to order the Vacurect RX.

STEP 1: PATIENT INFORMATION

STEP 2: INSURANCE INFORMATION

STEP 3: ASSIGNMENT OF BENEFITS

STEP 4: PROVIDE COPIES OF ALL INSURANCE CARDS, FRONT & BACK

STEP 5: PHYSICIAN INFORMATION & PRESCRIPTION

It is my professional opinion that a Vacuum Erection Device is medically necessary to treat my patient's erectile dysfunction.