Get American Independence Dynamic Afo Prescription Order Form 0

Filling out the American Independence Dynamic AFO Prescription Order Form 0 online is a vital step in obtaining the appropriate equipment for individuals who need assistance with mobility. This comprehensive guide offers a clear, step-by-step approach to ensure that you complete the form correctly and efficiently.

Follow the steps to fill out the form accurately and completely.

1. Click ‘Get Form’ button to access the order form and open it for completion.
2. Begin by entering the date in the designated field. Make sure to use the correct format of month, day, and year.
3. Fill in the 'Bill To' section by providing the account name, address, city, state, zip code, phone number, and fax number. If the shipping address is the same as the billing address, check the appropriate box.
4. If the shipping address differs, complete the 'Ship To Address' section with all necessary details, including address, city, state, zip code, phone number, and fax number.
5. Fill out the casting contact information, including a point of contact and email address. This ensures effective communication regarding the order.
6. Indicate the patient's demographic information by selecting gender, weight, and age. Choose the appropriate 'Activity Level' that reflects the patient's mobility capabilities.
7. Select the relevant diagnosis from the provided options or specify any other diagnosis in the blank space.
8. Describe the primary reason for the device in the corresponding field, ensuring it clearly explains the need for the AFO.
9. In the 'Clinical Observation' section, check the appropriate categories for both the ankle and forefoot conditions.
10. Select the type of footwear necessary, from the options provided, ensuring it meets the patient’s requirements.
11. Choose the corresponding options for 'Independence' indicating which leg(s) require the AFO (Left, Right, or Bilateral).
12. In the 'Forefoot Post' and 'Rearfoot Post' sections, select the type of post required, including any lab discretion to be considered.
13. Input the degrees for varus or valgus where applicable, and any necessary cast modifications for ankle circumference.
14. Choose the desired joint options, selecting Free Motion or Dorsi-Assist as relevant.
15. After completing all sections, review the form for accuracy and completeness. Save your changes before downloading, printing, or sharing the completed form.

Start the process now to ensure timely access to the necessary AFO support.