Orthoses Request And Justification (Page 2 of 2) in pdf

Orthoses Request And Justification Page 2

ORTHOSES

REQUEST AND JUSTIFICATION

SECTION 3 – ASSESSMENT

(TO BE COMPLETED BY ORTHOTIST, PEDORTHIST, PODIATRIST,

OCCUPATIONAL THERAPIST OR PHYSICAL THERAPIST)

NOTE: PLEASE ATTACH A DETAILED QUOTE.

SPECIFICATIONS OF THE ORTHOSES REQUIRED TO MEET THE APPLICANT’S NEEDS.

PLEASE EXPLAIN HOW THE PRESCRIBED ITEM WILL ASSIST WITH JOINT MOTION AND/OR SUPPORT.

IS THE ITEM REQUIRED FOR ONE OR MORE OF THE FOLLOWING PURPOSES?

A. PREVENTION OF SURGERY

YES

B. FOR POST SURGICAL TREATMENT

YES

C. TO ASSIST IN PHYSICAL HEALING FROM SURGERY, INJURY OR DISEASE

YES

D. TO IMPROVE PHYSICAL FUNCTIONING THAT HAS BEEN IMPAIRED BY A

YES

NEURO-MUSCULO-SKELETAL CONDITION

IF YES TO ANY OF THE ABOVE, PLEASE EXPLAIN

IF THE ORTHOSIS IS A CUSTOM-MADE FOOT ORTHOTIC,

WILL IT BE MADE FROM A HAND CAST MOLD?

YES, PLEASE EXPLAIN

IF THERE IS ANY OTHER INFORMATION THAT MAY BE RELEVANT TO THIS APPLICATION, PLEASE

EXPLAIN. (FOR EXAMPLE, WHAT IS THE CONDITION OF THE CURRENT DEVICE?)

PRINT NAME

DATE SIGNED (YYYY MMM DD)

SIGNATURE OF PERSON PROVIDING CLINICAL TREATMENT

POSITION/TITLE

PROFESSIONAL REGISTRATION NUMBER (IF APPLICABLE)

NOTE: Forward completed form to Ministry of Social Development and Social Innovation,

Health Assistance Branch, P.O. Box 9971 STN PROV GOVT Victoria, BC V8W 9R5

Page 2 of 2

HR2894(14/04/17)

Security Classification: MEDIUM SENSITIVITY

Orthoses Request And Justification Page 2