Revised May 2018

Employee/Member Name: _______________________________________________________
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