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    1695 Orthotics-Questionnaire PM Final

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    Ryan McDonald
    The document is a medical questionnaire for an orthotics claim. It requests information from a prescribing medical professional including symptoms, diagnosis, and biomechanical exam results. It also asks for details on the orthotics such as materials used and the manufacturing laboratory.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    1695 Orthotics-Questionnaire PM Final

    Uploaded by

    Ryan McDonald
    13 views2 pages
    The document is a medical questionnaire for an orthotics claim. It requests information from a prescribing medical professional including symptoms, diagnosis, and biomechanical exam results. It also asks for details on the orthotics such as materials used and the manufacturing laboratory.

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    Orthotics

    Original Title

    1695_orthotics-questionnaire_pm_final

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    © © All Rights Reserved

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    The document is a medical questionnaire for an orthotics claim. It requests information from a prescribing medical professional including symptoms, diagnosis, and biomechanical exam results. It also asks for details on the orthotics such as materials used and the manufacturing laboratory.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    13 views2 pages

    1695 Orthotics-Questionnaire PM Final

    Uploaded by

    Ryan McDonald
    The document is a medical questionnaire for an orthotics claim. It requests information from a prescribing medical professional including symptoms, diagnosis, and biomechanical exam results. It also asks for details on the orthotics such as materials used and the manufacturing laboratory.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Head Office

    One Westmount Road North


    P.O. Box 1603 Stn. Waterloo, Waterloo, Ontario N2J 4C7
    TF 1.800.265.4556 Fax 519.883.7404

    ORTHOTICS MEDICAL QUESTIONNAIRE AND CHECKLIST

    The following questionnaire must be completed and submitted for your claim to be considered for reimbursement.

    Please include the following with your submission:

    a completed claim form

    a copy of your paid receipt

    a copy of the laboratory invoice

    a copy of your referral (physician; podiatrist or chiropodist)

    Policy number: Certificate number:

    Member name: Patient name:

    This is for a (please select one): Estimate Health claim

    The following section must be completed by the prescribing medical professional (medical doctor, chiropodists or podiatrist)
    or by the medical provider who is dispensing the orthotics:

    1) What are the symptoms the patient is presenting with?

    2) What is the primary medical diagnosis or clinical impression that necessitates custom-made orthotics?

    The following must be completed by the podiatrist/chiropodist or medical provider who dispensed the product.

    3) Biomechanical exam and gait analysis summary:

    a) Non-weight bearing

    b) Weight bearing

    c) Summary of gait analysis


    T H E E Q U I TA B LE LIFE INSU RA NC E COMPANY OF CANADA 1695(2017/03/06) Page 1 of 2


    ORTHOTICS MEDICAL QUESTIONNAIRE AND CHECKLIST

    4) Was a cast impression of the patient’s foot taken? Yes No

    If “Yes”, please indicate the specific casting technique that was used to create the impression, and include the make and
    model number of any scanner.

    5) How was the orthotic constructed? Please indicate the raw materials used.

    6) What laboratory has or will manufacture the orthotics? Please include the full name, address and telephone number
    of the laboratory. If this is a claim, please attach a copy of the laboratory invoice.

    Medical Prescriber Fitter/Dispensing Practitioner

    Signature: Signature:

    Date: Date:

    Name, Address, Phone Number: Name, Address, Phone Number:

    Professional Qualifications: Professional Qualifications:

    Submission Instructions - Please keep a copy of your form and receipts for your own records.

    Electronic Submission: Visit www.equitablehealth.ca or www.equitable.ca and use our EZClaim online feature to submit your
    claim, along with your receipts and supporting documents. This is a secure and confidential portal for claim submission.

    T H E E Q U I TA B LE LIFE INSU RA NC E COMPANY OF CANADA 1695(2017/03/06) Page 2 of 2

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