RXTAFO170913
Rx : Thermoplastic AFO ( continued )
THERAPEUTIC OBJECTIVE ( S ): ( indicate all that apply )
� Improve mobility
� Improve lower extremity stability
� Decrease pain
� Facilitate soft tissue healing
� Facilitate immobilization , healing and treatment of an injury
Signature of Prescribing Physician : ______________________________ Type I NPI : _______________
Prescribing Physician Printed Name : ______________________________
( Must be current with CMS )
Order Date : ______/_______/_______
TM