Prior Approval Form Orthotics - Custom Footwear - Prosthetics - Pressure Garments

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PA#:
Date:

Section 1: Patient Information

Patient's Surname:
Date of Birth: (DD/MM/YY)
Given Name(s):
Sex: M | F
Band #:
Family #:
Client ID#:

Section 2: Prescriber Information

Prescriber's Name:
License / Billing #:
Telephone #:
Fax #:
Item Requested:

Section 3: Client Health Information

Diagnosis (should be specific to the item being requested):

Explanation of benefit requirement based on clinical assessment by recognized provider and specific details of device to be provided (MUST BE COMPLETED):

Will a follow up assessment be provided? Yes | No

Is the benefit requested due to the result of an injury? Yes | No
If yes, please complete the following:

Where did the injury occur? Home | Work | Other
When did the injury occur?

Are any of these expenses covered under any other public or private health care plan? Yes | No

Section 4: Equipment or Supplies Requested

• Description of Device (manufacturing technique, materials to be used, side of body, itemize replacement parts if it is a repair and details of warranty )
• Benefit Code
• Qty
• MFR Name (In-house or external?) MFR Item Code Class Type for orthoses/custom footwear

Section 5: Provider Information

Provider Name:
Provider #:
Provider Signature:
Date:
Telephone #:
Fax#:

Section 6: Client Signature

Client:
I have received the above mentioned item(s).
Signature:
Date: