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

Choosing a prosthetist is an important step in your recovery. Evaluating, problem solving, and fine-tuning your prosthetic device will be an ongoing process as your needs and abilities change over time. You 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 you.

Forms and Insurance Requirements

In addition to selecting your prosthetist, you will need to understand your 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 first visit are listed below. If you have any questions, please call us at 413-785-4047.

Forms and required 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.
  • Insurance companies require a physician’s notes for a prosthetic 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 prosthetist. Any relevant records from your vascular or orthopedic surgeon, physiatrist, primary care doctor, physical therapist, or other medical providers related to your condition will assist your prosthetist in recommending the most appropriate device and components for you and providing continuity of care.
  • In addition to your physician’s notes, a prescription 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 only:

A note about insurance coverage:

While all insurance plans require a prescription and physician notes for a prosthetic device, 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.

Request an appointment with a Prosthetist

Fill out the form below.

Are you an existing patient?* YesNo

What type of appointment are you looking for?*
Consultation/EvaluationAdjustment/Follow upSupply order/Refill

What side is your amputation on?
RightLeftBilateral

Is your amputation below the knee or above the knee?
Below the kneeAbove the kneeBilateral BK on one side and AK on the otherTransmetatarsal or partial foot amputation

If you're in need of supplies please check all that apply
LinersSocksShrinkers

Do you go to Wound Care? If so, which one?

Additional Comments

Upload any additional documents

Don’t forget you will need a prescription from your doctor for additional supplies if you would like us to bill your insurance.