Online Order Form
Please use this form to tell us what you would like to order. We follow up via email or phone call (your choice) to complete your order.
If you have Medicare, the following is a list of requirements for coverage:
Doctor's prescription with "GeeWhiz® External Male Catheter" as the prescribed item and "urinary incontinence" as the diagnosis.
Merlin Technologies, Inc. must have the original prescription or a Faxed copy before any billing may be done, as well as a signed copy of the Medicare Billing Authorization (See below).
Merlin Technologies, Inc. cannot accept assignment from Health Maintenance Organizations (i.e. Kaiser Permanente, HealthNet, etc.) at this time. Any HMO subscribers must pay for any supplies or services they receive.
A signed copy of the Medicare Billing authorization form. Click on the link to obtain a copy. This file is an Adobe PDF; if you do not have Acrobat Reader, a free downloadable copy is available at:
http://www.adobe.com/products/acrobat/readstep.html
Read this form and print it out. Sign it and mail it to us.
A clean, easily readable copy of all insurance cards (fax or copy is acceptable).
The following information is also required:
- Full name
- Home address, city, state and zip code
- Phone number (area code and number)
- Date of birth
All original documents (with the exception of insurance cards) must be mailed to Merlin Technologies with a Medicare order. Faxes will be accepted. For any questions call (800) 639.9323.
Note: Merlin Technologies will bill Medicare for qualified patients.