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West Springfield, MA (413) 785-4047 Bloomfield, CT (860) 904-2419

You must have a doctor’s order for any orthotic device. The prescription must come from your doctor, we cannot write one for you. If you do not already have a detailed prescription, your 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 first visit:

  • Consent form If possible, please print, complete, and bring this form to your first visit. Copies are also available in our office.
  • Medical release form PDF This is necessary for all forms of insurance. Copies are also available in our office.
  • Insurance companies require a physician’s notes for an orthotic device. Please have your medical records faxed to our office at 413-785-4048 ATTN: Medical Record. Your medical records are also extremely helpful to your orthotist. Any relevant information from your orthopedic surgeon, primary care doctor, physical therapist, or other medical providers will assist your orthotist in understanding your needs, recommending an appropriate orthosis for you, and providing continuity of care.
  • A prescription or consultation request from your 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 documents are for your information:

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 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.