Orthotics Form

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1. Medicare is your PRIMARY insurance

2. You have a prescription from your physician for a standard knee or back brace

3. You reside in a Medicare Competitve Bidding Area (CBA)

If you need assistance determining if you qualify under Medicare Competitive Bidding Program, please contact a store associate for additional information. We sincerely appreciate your contacting us and look forward to helping with your equipment needs!

If you meet ALL 3 of the above criteria and are ready to start the process, please hit NEXT to complete the form.
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Name* This field is required.
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Prescribing Doctor* This field is required.
First Name
Last Name
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Upload Your Script/Document(s):* This field is required.
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