* Denotes required fields. Type of Request: * Device Bio/Pharm Company Name: * 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 No 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 No 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. 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 No