UCI | Medicare/Medicaid 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

Date

Address

Street Address

Street Address Line 2

CityState

Zip Code

Best Phone Number

Format: (000) 000-0000.

E-mail

text@example.com

Will you be using

Private 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)

Are you requesting product for:

Do you currently receive medical products through any of these distributors?

Your Preferred Distributor's Contact Information

Please verify that you are human