For doctors and clinics
Order forms
Choose the item. Each form is one page: the order, the coverage criteria to check, and what the visit note must show. Fax the signed form with the patient's most recent visit note to (844) 438-5893.
- L0650
Back brace (LSO)
Open order form (PDF) - L1833
Hinged knee brace
Open order form (PDF) - L3916
Wrist hand orthosis
Open order form (PDF) - L1933 / L1952
Ankle foot orthosis (AFO)
Open order form (PDF) - L4361
CAM walking boot
Open order form (PDF) - E2103 / A4239
Continuous glucose monitor (CGM)
Open order form (PDF) - A5500 / A5512 / A5513
Diabetic shoes and inserts
Open order form (PDF) - T4521–T4543, T4535, A4554
Incontinence supplies (NY Medicaid)
Open order form (PDF)
Need more than one?
Download all eight forms in one PDF, or call (917) 300-2692 and we will fax them to your office.
Signature and date stamps are not acceptable. The forms do not replace the practitioner's own medical record.
Find out if you're covered
Answer five quick questions, or call us. We check your benefits for you.