UCI | Medicare/Medicaid Referral Form

Referral Form
Please complete the information below and we will submit it to a distributor to process your Medicare or Medicaid, so you can begin receiving our URO product.

NOTE: If you choose to call your order in yourself, please make sure to confirm both, the HCPCS Code: A5105 (Urinary Suspensory) and the item# as listed here, to ensure the correct product and size are sent to you.

Accept NO SUBSTITUTIONS. Please alert us if there is a shortage, due to demand, and we'll work to remedy it for you. Thank you.
Full Name*

PrefixFirst NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Best Phone Number*
E-mail*
text@example.com
Will you be using*

MedicareMedicaidPrivate Insurance Provider
ID#/Group#*
Medicare/Medicaid or Private Insurance*
Doctor's Name*
Doctor's NPI# (optional)
Doctor's Phone#*
Office Phone
Doctor's Fax#*
Please Confirm Product Item#/Size (waist size)*

SMALL (28"-30") UCIURO4SMEDIUM (32"-34") #UCIURO4MLARGE (36"-38") #UCIURO4LX-LARGE (40"-42") #UCIURO4XL2X (44"-46") #UCIURO42X3X (48"-50") #UCIURO43X
Are you requesting product for:*

3 months (90-Day Supply)1 month
Do you currently receive medical products through any of these distributors?*

NoneComfort MedicalCardinal At-HomeEdgePark180 MedicalOther - Please Enter Company Name
Your Preferred Distributor's Contact Information
Please verify that you are human*
Should be Empty: