WORKING TOGETHER TO IMPROVE THE LIVES OF OUR PATIENTS.

The first step in getting a customized prosthesis for your patients is to send us a referral. We will still be able to come out and perform a consultation before we receive an official referral. However, we would prefer to have the referral as soon as possible so that we may begin to gather the necessary paperwork, and provide your patient with some stump shrinkers to help prepare their limb to be casted for a prosthesis. We have prepared a description below of what your referral needs to consist of to be considered valid for a prosthesis.

 

Our Forms:

You may use the link below to generate a blank copy of a referral that we have created. In order to ensure timely processing, please completely fill out the form before sending it back. You may return the completed referral to us by fax. You can find our contact information on the header of the document. Unless you have access to a secure email service, please refrain from sending referrals or other patient information by email.

 

Click the logo for our blank referral!

 

Your Forms:

In order for the referral to be recognized as valid by Medicare and other insurance providers it should contain the following information:

  • The patient’s legal first and last name.
  • The patient’s date of birth.
  • The side and level of amputation.
  • Your full name and credentials.
  • Your signature.
  • The date you signed the referral.
  • Somewhere on the referral it must specify that we are to evaluate and treat for a prosthesis.

The simplest way to create a referral is to use a prescription pad. If you wish, you may also dictate the order to another member of your staff, or ours. As long as the information is properly recorded it will be sufficient for use as a referral.

Additional Resources:

In addition to a referral we will also need other information regarding the patient you would like to refer to us. This includes a Detailed Written Order, which includes a breakdown of all of the features we would like to use for the patient’s prosthesis, as well as a justification of each of those features. We will send you the Detailed Written Order AFTER our prosthetist has been out to formally evaluate the patient.  We will also need a copy of your patient’s most recent medical records that indicate a medical need for a prosthesis. For a comprehensive and informative guide as to what these notes should include, please follow the link below. By following the guidelines we have specified, as well as the format for notes that is described in the pamphlet linked below, you will help us ensure that every patient receives their prosthesis in a timely manner.

Click here for Ottobock’s guide on referring patients for a prosthesis.