Before Prosthetics Visit, Pediatric

Before Your Child’s Prosthetics Visit

Choosing a prosthetist is an important step in your child’s recovery. Evaluating, problem solving, and fine-tuning a prosthetic device will be an ongoing process as your child’s needs and abilities change over time. You and your child should feel confident that your prosthetist is highly skilled and a patient and caring listener. We encourage you to schedule a no-fee, no-obligation consultation as you consider the right prosthetist for your child.

Forms and Insurance Requirements

In addition to selecting your child’s prosthetist, you will need to understand insurance coverage. We appreciate that this can be a complicated process, and we are here to help you. Forms and information you will need for your child’s 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 possible, please print, complete, and bring this form to your first visit. Copies are also available in our office.
  • Medical release form This is necessary for all forms of insurance. Copies are also available in our office.
  • Insurance companies require a physician’s notes for a prosthetic device. Please have your child’s medical records faxed to our office at 413-785-4048 ATTN: Medical Records. These records are also extremely helpful to your child’s prosthetist. Any relevant notes from your child’s orthopedic surgeon or neurosurgeon, pediatrician, physical therapist, early intervention therapist, or other medical providers will assist your child’s prosthetist in understanding your child’s needs, recommending an appropriate device, and providing 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.

  • Privacy & Financial Policies
  • Medicare Supplier Standards English Spanish
  • Patient Bill of Rights
  • HIPAA 

A note about insurance coverage

While all insurance plans require a prescription and physician notes, every plan is different. Additional requirements vary by individual and company. 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.