Get Nihb Orthotics - Custom Footwear

This guide provides step-by-step instructions for completing the NIHB Orthotics - Custom Footwear form online. It aims to ensure that users have a clear understanding of each section and field within the form, making the process smoother and more accessible.

Follow the steps to complete the NIHB Orthotics - Custom Footwear form.

1. Press the ‘Get Form’ button to access the form and open it in your chosen editing tool.
2. Begin with Section 1: Client Information. Fill in the client's surname, given name(s), date of birth, sex, street address, city, province or territory, postal code, client ID number, or band number, as well as the family number.
3. If the client is under one year of age and not registered, proceed to Section 2: Parent/Legal Guardian/Representative. Provide the necessary information, including the parent’s or guardian's surname, given name, date of birth, client ID number, or band number, and family number.
4. In Section 3: Prescriber Information, write the name and title of the prescriber, along with their license or billing number, telephone, and fax number.
5. Navigate to Section 4: Client Health Information. Detail the diagnosis, provide an explanation of the benefit requirement, and indicate if a follow-up assessment will be provided. Specify whether the item addresses a permanent or temporary condition and if the benefit requested is due to an injury, providing additional details as necessary.
6. For Section 5: Equipment or Supplies Requested, include a description of the device, manufacturing technique, materials, quantity, cost, and other details required by the benefit code. Include the manufacturer name and item code if applicable.
7. Complete Section 6: Provider/Fitter Information, including the provider name, provider number, fitter name, specialty, telephone, and fax number.
8. Ensure that the provider certifies the information by signing and dating the form.
9. Once all sections are completed, save your changes, and download or print the form as needed for submission.

Complete your NIHB Orthotics - Custom Footwear document online today!