Device or Bio/Pharm Support Request Form

* Denotes required fields.

Type of Request: *

Device

Bio/Pharm

Company Name: *

All form fields with * are required

Address Line 1: *

Address Line 2:

City: *

State/Province/Region: *

Postal/Zip Code: *

Country: *

Contact Person: *

Email: *

Phone: *

Name of Treatment/Service/Product Device: *

What urologic condition does this treat?: *

Briefly describe treatment and how it is utilized: *

Is this treatment/product/device the only such in its class?: *

Has FDA approval been granted?: *

Yes

If yes, when was the approval granted?:

If no, when is the anticipated approval date?:

Describe what efforts have already been made with agencies and insurers to address concerns and what solutions have been offered.: *

What proprietary cost or pricing information is necessary to review this request?: *

Is there published peer-reviewed English-language literature published?: *

Yes

The AUA requests any marketing materials, peer-reviewed literature and any other information to assist in providing a full picture of the treatment/procedure/service/device and the purpose of the request. Please upload your information here. If you have additional materials, please indicate in the block below and when contacted after receipt of this request, additional information can be provided.

File Attachments

(Note: The filename should not should contain any punctuation, special or foreign characters.)

Allowed file types: PDF, PNG, JPG, JPEG, GIF, DOCX

The maximum total file size for all documents should be less than 4MB. Total file size submissions exceeding 4MB may result in an error and delays with processing your application.

1. Marketing Materials, Peer-Review Literature and any other Information:

2. Marketing Materials, Peer-Review Literature and any other Information:

3. Marketing Materials, Peer-Review Literature and any other Information:

4. Marketing Materials, Peer-Review Literature and any other Information:

Does additional information need to be submitted?:

Yes

Device or Bio/Pharm Support Request Form

File Attachments

American Urological Association

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