Procedure Ready Program
patient enrollment form

For internal use, only

Please fill out the following fields to enroll a patient. Click here to enroll the patient in the Spanish version of this program.

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This field is for validation purposes and should be left unchanged.

Enrollment source(Required)

First name(Required)

Last name(Required)

Email address(Required)

Phone number(Required)

Date of birth(Required)

Choose a surgeon(Required)

Filter by your stateChoose your surgeon

Medical clearance?(Required)

Has the patient’s physician asked them to get medical clearance from another care provider (examples: Primary Care, Cardiology)?

This patient's procedure is scheduled for approximately:(Required)

Scheduled date of procedure (if known)

Insurance type(Required)

Commercial insurer(Required)

Insurer name (other)(Required)

Under this policy, implantation of a penile prosthesis is considered medically necessary for individuals who meet certain criteria. Your doctor should be able to help you understand this criterion, follow this link for general standards. Click Here for general standards.

Medicare or Medicare Advantage Plan provides coverage for penile implant surgery and all other Coloplast devices, as long as they meet criteria for being medically necessary. Your doctor should be able to help you understand these criteria. Patient payments are estimated between $2,500 and $3,000 unless there is a secondary or supplemental plan. Click Here to learn more about general criteria for Medicare coverage of penile implant prosthesis.

Medicaid coverage for Coloplast products varies a great deal, particularly for penile prostheses. Your physician should be able to advise you about local coverage, or you can contact the Medicaid program directly for answers about coverage. Click Here to learn more about general criteria for Medicaid coverage of penile implant prosthesis.

The Coloplast Procedure Ready Program is a free educational program designed to educate patients about upcoming Coloplast implants. The program includes individualized product information and information about your implant procedure which may include a welcome kit, and on-going text and email information. As part of the Procedure Ready Program, you will receive text and email-based communications about your upcoming implant. Communications may include personalized emails and texts about your Coloplast implant containing website links to articles, advice, reminders, inspirational stories, and answers to lifestyle questions that may be of interest.

By submitting your personal information above, you agree to enroll in the Procedure Ready Program for your upcoming implant procedure. We may use the information you share with us to help us understand our customers, their medical conditions, and their needs when treating them. We also use your information to conduct research and data analytics. This helps us to improve our products and services and to develop new ones. We will not share or sell your information to third parties other than to contact your provider who referred you to us for purposes of gathering insurance criteria. You may opt out at any time.

By submitting the information on this form, you acknowledge that you agree to be contacted and accept Coloplast’s Confirmation of Consent and Privacy Policy.

PM-22106

Procedure Ready Programpatient enrollment form

Procedure Ready Program
patient enrollment form