Thermoplastic AFOs Compliance Documentation Packet | Page 7

RXTAFO170913
Proof of Delivery : Thermoplastic AFO
Supplier Name : _______________________________________
lnstructions For Use :
You have been dispensed this custom molded ankle brace to immobilize your foot and ankle . An AFO often requires a period of adjustment . It is best to wear it for one hour more each day and to continue this for two weeks . It should only be removed as specifi cally instructed . If the brace feels too tight , you may be walking too much . Get off your feet , loosen any straps and elevate your foot until the tightness resolves . If your symptoms do not resolve , please contact our offi ce immediately . Should the device crack or break , remove it and do not use it again until you contact our offi ce . Straps , laces should be kept clean of clothing fabric
HICN : __________________________
Product Information ( Check brand and model , circle base code and addition ( s )):
� Arizona Optima Brace , Standard , Restricted
� AZ CROW Walker ™
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L
L1970 An articulated molded plastic orthosis with ankle joints that allow for free motion of the ankle , ( dorsi-plantar fl exion ), custom molded from a model of the patient , custom fabricated , includes casting and cast preparation .
R
L
L2820 Addition to lower extremity orthosis , soft interface for molded plastic below knee section .
� Arizona Thermoplastic AFO - Articulated , Dorsi-Assist
R
L
L1970 Articulated molded plastic orthosis with ankle joints , custom molded from a model of the patient , includes casting and cast preparation .
R
L
L2210 Addition to lower extremity , dorsi-fl exion assist ( plantarfl exion resist ), each joint .
� Arizona Thermoplastic AFO - Articulated
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L
L1970 An articulated molded plastic orthosis with ankle joints that allow for free motion of the ankle , ( dorsi-plantar fl exion ), custom molded from a model of the patient , custom fabricated , includes casting and cast preparation .
� Arizona Thermoplastic AFO
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L
L1960 A molded plastic ankle foot orthosis , posterior solid ankle trim lines , custom molded from a model of the patient , custom fabricated , includes casting and cast preparation
R
L
L4631 A bivalved custom molded plastic orthosis , with
a removable custom arch support , soft interface , and
a rocker bottom walking sole . For patients with Charcot .
� Split Upright AFO
R
L
L1970 An articulated molded plastic orthosis with ankle joints that allow for free motion of the ankle , ( dorsi-plantar fl exion ), custom molded from a model of the patient , custom fabricated , includes casting and cast preparation .
R
L
L2820 Addition to lower extremity orthosis , soft interface for molded plastic below knee section
� Split Upright AFO , Dorsi-Assist
R
L
L1970 An articulated molded plastic orthosis with ankle joints that allow for free motion of the ankle , ( dorsi-plantar fl exion ), custom molded from a model of the patient , custom fabricated , includes casting and cast preparation .
R
L
L2210 Addition to lower extremity , dorsi-flexion assist ( plantarflexion resist ), each joint .
R
L
L2820 Addition to lower extremity orthosis , soft interface for molded plastic below knee section
� Supramallleolar Orthosis
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L
L1907 Ankle orthosis , supramalleolar , with straps , with or without pads , custom fabricated
to insure the device is properly secured to your extremity . Applying a skin moisturizer and wearing knee high socks will prevent your skin from irritation .
Material failure warrantee coverage :
• Hardware , plastic and metal component are covered at no-charge for six months .
• All soft materials : material covers , Velcro straps and limb support pads , are covered at no-charge up to ninety days at no-charge up to ninety days .
I have read the posted Complaint Resolution Policy and have been provided with a copy of the Medicare Supplier Standards . I certify that I have received the item ( s ) indicated . The supplier has reviewed the instructions for proper use and care and provided me with written instructions . I understand that failure to properly care for this item ( s ) will result in the warranty being voided . This could result in my responsibility for future repair or replacement costs if my insurance policy will not cover such costs . The supplier has instructed me to call the office if I have any difficulties or problems with the device .
Patient Signature _____________________________________
Printed Patient Name ___________________________________
Date Delivered : _____ /______ / _____
Patient Address _____________________________________
Original in patient ’ s chart , copy to patient
_____________________________________
The codes contained herein are not the official position or endorsement of any organization or company . They are offered as a suggestion based upon input from previous customers . Each prescribing practitioner should contact his or her local carrier or Medicare office to verify billing codes , regulations and guidelines relevant to their geographic location .
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