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800-373-7006
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Contact Us
1
Product Info
2
Personal Info
3
Insurance Info
There are 4 easy steps to receive your Men's Liberty Male External Catheter supplies with little or no cost from your insurance company. Simply complete the following steps and we will take care of the rest. If you still have questions before you get started, give us a call at
800-373-7006
.
Step 1: Select Your Supply
Pick Your Supply
35 Days
90 Days
KindKlamp™
Yes
No
Bed Bags
Yes
No
We are here to help. If you have questions, give us a call at
800-373-7006
.
Step 2: Patient Information
First Name.
*
Last Name
*
Date of Birth
*
Month
1
2
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12
Day
1
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Year
2023
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1927
1926
1925
1924
1923
1922
1921
1920
Address
Street Address 1
*
Street Address 2
City
*
State
*
State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
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NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
*
Primary Phone Number
*
Secondary Phone Number
Email Address
*
Contact Method
*
Select Contact Method
Primary Phone
Secondary Phone
Email
Doctor Name
*
Doctor Phone Number
*
Diagnosis
*
Select Diagnosis
Geriatric Incontinence
Prostate Cancer
Enlarged Prostate
ALS
Alzheimers/Dementia
Bladder Cancer
Cerebral Palsy
Diabetes
MD
MS
Neurogenic Bladder
Paraplegic
Parkinsons
Quadraplegic
Spina Bifida
Spinal Cord Injury
Spinal Injury (non para/quad)
Stroke
Traumatic Brain Injury
Other
Home Health
*
Do you have a nurse, aid, or physical therapist that visits you at home?
Yes
No
Home Health Release Date
*
MM slash DD slash YYYY
Caregiver Name
Additional Notes
Please complete this last step. We will take care of contacting your doctor and your insurance company. We will contact you when the process is complete. In the meantime, if you have questions, give us a call at
800-373-7006
.
Step 3: Insurance Information
Primary Insurance Company
*
Primary Insurance Phone
*
Primary Insurance ID Number
*
Secondary Insurance Information (Optional)
Secondary Insurance Company
Secondary Insurance Phone
Secondary Insurance ID Number
