Get American Independence Afo Prescription Form

Filling out the American Independence Afo Prescription Form online is a crucial step for obtaining the necessary orthotic support. This guide will walk you through each section of the form, ensuring that you provide all required information accurately and efficiently.

Follow the steps to complete the form online

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. In the 'Bill To' and 'Ship To' sections, fill in the respective account name and address fields. If the shipping address is the same as the billing address, check the 'Ship To Same as Bill Address' option.
3. Enter the date in the designated format as ___/___/___ to indicate when the order is being placed.
4. Provide the patient's details such as name, weight, age, and activity level. Choose one from the activity level options that best describes the patient's mobility.
5. Select the diagnosis from the available options: Posterior Tibial Tendon Dysfunction, Degenerative Joint Disease, Severe Pronation, Trauma, or specify 'Other' if applicable.
6. In the 'Primary reason for the device' section, explain the main purpose for which the AFO is being requested.
7. Indicate the clinical observations related to the patient's ankle and forefoot flexibility, check the appropriate boxes based on the assessment.
8. Under 'Footwear', select the type of footwear the patient is using — options include Comfort, Athletic, Extra Depth, Custom Molded, or Shoe Enclosed.
9. For the ankle independence options, specify whether the AFO is required for the left side, right side, or bilaterally.
10. Complete the sections regarding the forefoot and rearfoot post choices, ensuring to select the correct post options or indicate lab discretion if necessary.
11. Fill in the circumferences and modifications as required, indicating if any adjustments should be made based on the patient's needs.
12. At the end of the form, review all information entered for accuracy and completeness. Once completed, you can save changes, download, print, or share the form as needed.

Start filling out your American Independence Afo Prescription Form online today to ensure timely processing of your request.