Beneficiary Information

Please fill out the patient information below to begin the Bracing and Orthotic documentation process. Accurate identification details are essential for ensuring CMS compliance.

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Patient Name *

Medical Record Number (MRN) *

Date of Birth (DD/MM/YYYY) *

Medicare Beneficiary Identifier (MBI) *

Item(s) Ordered *

• Knee Brace
• Ankle-Foot Orthosis (AFO)
• Wrist-Hand Orthosis (WHO)
• Cervical Collar
• TLSO (Thoracic-Lumbo-Sacral Orthosis)
• Other

If Other, please specify

Affected SideLeftRightBilateral

HCPCS Code (if known)

Placeholder: e.g., L1832

Accessories / Modifications (if applicable)

Placeholder: e.g., Straps, liners, padding adjustments

Beneficiary Justification of

Quantity Ordered *

Medical Necessity / Clinical Justification *

Please describe the clinical reason for prescribing the brace or orthotic device.

Relevant Diagnosis Code(s) (if available)

Relevant Diagnosis Code(s) (if available)

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