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 System Prescription 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 Y185.0 Carcinoma ❑ No The T of rree the is document documenta of Medical c No cal NDiabetes t Supporting tes Ere rectile❑Dysfun D 401.9ction. Please supply notes ttes with pres r cription. c ❑ Prostateation ❑ 250.00 MellitusEr Hypertension SAFETY CONCERNS Most Cur Curr urrrent ent Date t wa te w s eval valu val aluated t ffor the ccondition of Er ted Ere rectile Dysfun D ction or Organic rganic r Impoten t ce: c T Vacuum This V T ra The rap apy py Sys S ttem is mediccally necessa c ry r ffor the above vvee diagnosis diagnosis. Physician Name: _______________________________________________NPI#____________________________________ Address: __________________________________ City: _________________________ State:______ Zip: _____________ Phone: _____________________________________________________ Fax: ___________________________________ “I pres r crib res c e and re r quest eest this va v ccuum thera rap ra appyy syste t m for f m my patient named above vve beca c use u the vac v uum thera ra rap appyy sy syssttem em is medic medically cally neces cess essary ry.y”. ry I have v revie ve r we w d the above v info ve f rm fo r ation for f comple c t eess and accu ten c ra r cy cy.y. 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