Thermoplastic AFOs Compliance Documentation Packet

DCNPAFO170913

WorryFree DME Compliance Documentation Packet

To be completed by physician :

Biomechanical Evaluation Form ( Medical Record Information )

� Documents medical necessity

Document of Medical Necessity

� Justifies qualification for use of AFO

� Details reason for prefabricated versus custom device

� Justifies level of fitting ( off-the-shelf versus custom-fitted )

� Justifies code ( s ) selected

Prescription

� Description of the items

� Patient Name

� Physician ’ s printed name

� Diagnosis

� Physician ’ s signature ( no stamps allowed )

� Date ( no stamps allowed )

� Indication if right and / or left limb affected

To be given to Patient :

Proof of Delivery

� Patient Printed Name

� Date of delivery

� Item Description

� Item Code ( s )

� Patient Signature

� Patient Address

DMEPOS Supplier Standards

To be completed by Supplier / Physician :

Dispensing Chart Notes

� Type of orthosis

� Describes method of fitting

� Documents patient satisfaction

* Confirms delivery of Supplier Standards