Before Orthotics Visit, Pediatric

Before Your Child’s Orthotics Visit

We must have a doctor’s order to provide your child with an orthotic device. The prescription must come from your child’s doctor, we cannot write one for you. If you do not already have a detailed prescription, your child’s physician can forward a consultation request to our office. If you are unsure how to proceed, please contact our office to discuss your needs.

Forms and Insurance Requirements

Navigating the insurance process can be complicated, and we are here to help you. Forms and information you will need for your first visit are listed below. If you have any questions, please call us at 413-785-4047.

Required forms and medical documentation for your child’s first visit:

  • Consent form If you prefer, you may print, complete, and bring this form to your first visit. Copies are also available in our office.
  • Medical release form This is necessary for insurance. Copies are also available in our office
  • Insurance companies require a physician’s notes for an orthotic device. Please have your child’s medical records faxed to our office at 413-785-4048 ATTN: Medical Records. Any relevant information from your child’s orthopedic or vascular surgeon, primary care doctor, physical therapist or other medical providers will help your orthotist understand your child’s needs, recommend an appropriate device, and provide continuity of care.
  • A prescription or consultation request from your child’s doctor is required. You do not need a prescription for a consultation appointment. However, once you decide to move forward with a device we will need a doctor’s order to bill insurance.
  • Please note: MassHealth Primary Care Clinician Plans (PCC) require a referral from your primary care physician. Please have your doctor’s office submit a referral through the MassHealth provider portal. Our NPI# is 1558376913.

The following forms are for your information. They DO NOT need to be completed or signed.

A note about insurance coverage for orthotic devices

Every insurance plan is different, and within individual plans requirements can vary based on the specific orthotic device prescribed. We will work with you to help you understand your plan, assist you with requesting the appropriate documentation, and prepare you for any portion of the cost that will be your responsibility. Please call us at 413-785-4047 for information about what your insurance plan requires.