Custom Orthotic RX Form - Langer Biomechanics
This document is a custom orthotic prescription form from Langer Biomechanics. It includes sections for patient information, examination findings, orthotic specifications, and payment details. Follow the instructions to complete and submit the form for custom orthotic fabrication.
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How do I fill this out?
To fill out this form, start by entering the patient and practitioner information. Follow the instructions for each section to specify the orthotic requirements and examination findings. Ensure all fields are completed accurately before submission.
How to fill out the Custom Orthotic RX Form - Langer Biomechanics?
1
Enter patient and practitioner information.
2
Detail examination findings.
3
Specify orthotic requirements.
4
Complete payment information.
5
Review and submit the form.
Who needs the Custom Orthotic RX Form - Langer Biomechanics?
1
Podiatrists need this form to prescribe custom orthotics for their patients.
2
Orthopedic specialists use this form to specify details for orthotic fabrication.
3
Patients who require custom orthotic devices need this form for accurate measurements and specifications.
4
Clinics use this form to streamline the custom orthotic ordering process.
5
Insurance companies may require this form for reimbursement of custom orthotic devices.
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What are the instructions for submitting this form?
To submit this form, ensure all sections are completed accurately. You can submit via email to the provided address, fax to the listed numbers, or mail to either address: 160 Markland Street, Markham, ON L6C 0C6 or 2905 Veterans Memorial Highway, Ronkonkoma, NY 11779. For further assistance, contact customer support.
What are the important dates for this form in 2024 and 2025?
The important dates for this form are subject to the practitioner's or clinic's schedule. Ensure timely completion to avoid delays in orthotic fabrication.
What is the purpose of this form?
The purpose of this form is to provide detailed information required for the fabrication of custom orthotics. It includes sections for patient demographics, examination findings, and specific orthotic preferences. By completing this form, practitioners can ensure that the custom orthotics meet the patient's needs and specifications.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes fields for patient's name, address, sex, age, and shoe size.
- 2. Practitioner Information: Includes fields for practitioner's name, address, phone, and email.
- 3. Examination Findings: Records details such as foot motions, ankle dorsiflexion, subtalar joint motion, and other examination results.
- 4. Orthotic Specifications: Allows practitioners to specify the type of orthotic, materials, and any special modifications.
- 5. Payment Information: Includes options for payment method, card details, and Protect® Program serial number.
- 6. Submission Details: Sections for recast authorization, P.O. number, and lab use only fields.
What happens if I fail to submit this form?
Failing to submit this form can result in delays or errors in the fabrication of custom orthotics. Accurate and timely submission is crucial for effective treatment.
- Treatment Delays: Submitting the form late can cause delays in receiving the custom orthotics.
- Fabrication Errors: Incomplete or inaccurate forms can lead to errors in the orthotic specifications.
- Insurance Issues: Without the form, insurance claims for reimbursement may be denied.
How do I know when to use this form?
- 1. Initial Prescription: When a patient is prescribed custom orthotics for the first time.
- 2. Replacement Orthotics: To request a new pair of orthotics if the existing pair is worn out or no longer fits.
- 3. Orthotic Adjustments: To make adjustments or modifications to an existing pair of orthotics.
- 4. Insurance Reimbursement: For insurance claims that require detailed prescription forms.
- 5. Clinical Records: To maintain accurate records of patient orthotic prescriptions and specifications.
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