Prepayment Information

Click Here for the Upper Extremity Measurement Form

Click Here for the Patient Information Sheet

If you do not wish to order a custom product, Click Here for the Prefabricated/Semi-Custom Orthotics and Therapy Aids Order Form

Order by Prepayment

We use California MediCare pricing for all of our custom orthotics. Every order will be assessed a delivery/handling charge.  Our invoices will have a procedural breakdown for each orthosis for insurance reimbursement purposes. When seeking reimbursement, the patient can submit our invoice marked "paid" coupled with the prescription for the orthosis to their insurance company.  The patient's diagnosis needs to be on the doctor's prescription.  In some instances, insurance companies may request that a Letter of Medical Necessity be provided, and this should be provided by a Physician. We cannot guarantee insurance reimbursement on any items due to the differences in individual policies and circumstances. You may wish to consult with your insurance provider prior to ordering.
 
There are also a few optional items that may not be reimbursed through insurance. For this reason, we have kept these items at a minimal cost.  In addition, insurance companies generally do not reimburse for casting, fitting, delivery, or shipping costs.

To view a sample prescription form click here 

To view a sample prescription form for the PRO click here
 
FOR UPPER EXTREMITY ORTHOTICS

• Once we receive the completed Upper Extremity Measurement Form (click to view), the completed Patient Information Sheet (click to view) and a copy of the prescription with the diagnosis on it, a price can be determined for an order. We will notify the billing party (patient/therapist/facility) of the total price, including delivery and handling charges, within two business days.
• Once we receive payment the brace will then be shipped to the therapist within 8 business days.
• Upon delivery, the therapist must do the fitting.

• We must receive the completed Patient Information Sheet (click to view), video of the patient walking, and a copy of the patient's prescription with the diagnosis on it, before we can process an order.  Once all items have been received via email, fax or mail, a price can be determined for an order.  We will notify the billing party (patient/therapist/facility) of the total price, including delivery and handling charges, within two business days.
• A cast will then need to be taken of the patient and sent to us via mail along with the payment in the form of a check or credit card payment.
• The brace will then be shipped to the therapist within 8 business days.
• Upon delivery, the therapist must do the fitting.

• We must receive the completed Patient Information Sheet (click to view), and a copy of the prescription with the diagnosis on it, before we can process an order.  Once all items have been received via email, fax or mail, a price can be determined for an order.  We will notify the billing party (patient/therapist/facility) of the total price, including delivery and handling charges, within two business days.
• If ordering the PRO Insole™ at the same time your are ordering the Perfect Response Orthotic® or within 3 months of ordering the Perfect Response Orthotic® a cast does not need to be taken.  If ordering the PRO Insole™ after 6 months of ordering the Perfect Response Orthotic® or if the patient never ordered the Perfect Response Orthotic® then a cast will then need to be taken of the patient and sent to us via mail along with the payment in the form of a check or credit card payment.
• The brace will then be shipped to the therapist within 8 business days.
• Upon delivery, the therapist must do the fitting.

IF PAYING BY CREDIT CARD PLEASE COMPLETE CREDIT CARD ORDER FORM BELOW AND FAX, EMAIL, OR MAIL IT TO US.  Click Here for the Credit Card Order Form