Patient Forms

Below, you will find certain forms that may be required for you to download and complete. There are also some brochures you may find useful. For more information, please contact us.

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Orthotic

Bracing for the Upper and Lower Limbs


Orthotic Intake Form

Pedorthic

Shoes and/or Shoe Inserts


Pedorthic Intake Form

Spinal

Back and Neck Bracing


Spinal Intake Form

Limbs For Life

Limbs For Life is a national organization who covers the cost of a basic prosthesis. The application is based on income level. The final page of the application also must be completed by a prosthetist. For more information go to http://limbsforlife.org/get-help/

Apply Today

Amputee Coalition

The Amputee Coalition provides financial assistance for prosthetics, durable medical equipment, and other assistive devices. Financial assistance options can be viewed below.

Financial Assistance Options

Medicare

For more information go to https://www.medicare.gov/

Apply Today

Medicare Supplement - Medigap

Medicare supplement plans aim to help cover what Medicare does not. It covers some deductibles, co-insurance, co-payments, and other costs not covered by Medicare Parts A & B.

For more information go to https://www.medicaresupplement.com/ or call 855-309-7322 to speak with an agent.

NOTE: You cannot buy a Medigap policy if you have a Medicare Advantage Plan unless you first disenroll from the Medicare Advantage policy.

Medicaid

For more information go to http://www.medicaid.gov/index.html

To see if you qualify, go to https://www.healthcare.gov/medicaid-chip/eligibility/

Mending Limbs

For more information go to http://www.mendinglimbs.org/

Apply Today