Revised May 2018
Employee/Member Name:_______________________________________________________
Patient Name:_______________________________________________________
Policy/Plan Number:_______________________________________________________
Certificate/ID Number:_______________________________________________________
Patient DOB:_______________________________________________________
Information must be clear, concise, and legible. Proper medical terminology and anatomical terms must be included. If acronyms are used, there must be a legend explaining the terminology.
Clinical assessment findings
1. Diagnosis/clinical impression that necessitates orthopaedic footwear using appropriate anatomical and medical terminology
• Congenital deformity (e.g., clubfoot):_______________________________________________________
• Disease process (e.g., Charcot):_______________________________________________________
• Injury/trauma (e.g., stroke): _______________________________________________________
• Foot deformity:_______________________________________________________
2. Relevant clinical assessment/biomechanical examination/gait analysis findings that necessitate footwear: _______________________________________________________
3. Date of assessment: _______________________________________________________
Date of dispensing/fitting: _______________________________________________________
Pre-fabricated/mass-produced orthopaedic footwear
1. Make and model of footwear:_______________________________________________________
a. Size and width: _______________________________________________________
2. If modifications performed, please list: _______________________________________________________
Custom-made orthopaedic footwear
1. Outline the manufacturing process: _______________________________________________________
a. Foot capture/casting/scanning technique. If digital, include the brand name and model of the scanner: _______________________________________________________
b. Materials used: _______________________________________________________
c. Specific features to accommodate foot deformity: _______________________________________________________
The following must also be included with your submission:
i) Completed claim form
ii) Referral from a qualified prescriber
iii) Itemized paid receipt (including payment date and type)
iv) Copy of the lab/manufacturing facility packing slip or invoice including name, address, and phone number (copy of lab order in cases where the dispenser is the manufacturer)
v) Two sets of photos: (1) of patient’s feet; and (2) of custom-made footwear dispensed **this is for custom-made footwear claims ONLY**
Provider information
Clinic name: _______________________________________________________
Address: _______________________________________________________
Phone: _______________________________________________________
Professional qualifications: _______________________________________________________
College registration number:_______________________________________________________
Date: _______________________________________________________
Canadian Certified Pedorthist Name: _______________________________________________________
Signature: _______________________________________________________
For more information, contact the Pedorthic Association of Canada at 1-888-268-4404 or info@pedorthic.ca.
Download – A Resource for Canada’s Insurance Industry as a PDF