Orthotic and Prosthetic Device

(O&PF) Orthotic & Prosthetic Form – Ver 1.1 – Sep 2021

    1. Applicant Name (required)

    2. Email Address (required)

    3. Address (required)

    4. City (required)

    5. State (required)

    6. Country (required)

    7. Zip Code (required)

    8. Phone Number (required)

    9. Are you a single parent?

    10. Are you a United States Resident?

    11. Are you a resident of California, Florida, Texas or Wisconsin?

    12. Patient Name (required)

    13. Age of Patient (required)

    14. Do you have other children with current ORTHOTIC AND PROSTHETIC DEVICE treatment?

    15. If so, how many?

    16. Are you or a family member coping with any other health issues? If so, please explain:

    17. Do you currently volunteer, or do you have an immediate family member who does? If so, who and how many hours have you completed in the last 12 months?

    18. Average Household Income (required)

    19. How did you find out about Align Scoliosis Foundation? (required)

    20. It is recommended that you wear your ORTHOTIC AND PROSTHETIC DEVICE as was prescribed by your MD. Will you:

    21. Who is the prescribing Medical Doctor? (required)

    22. Who is the orthotist providing the ORTHOTIC AND PROSTHETIC DEVICE? (required)

    23. What is the type of ORTHOTIC AND PROSTHETIC DEVICE you are applying for this funding?

    24. What is the name of the ORTHOTIC AND PROSTHETIC DEVICE provider company? (required)

    25. What type of Insurance do you currently have? (required)

    26. How much is the insurance company going to pay for the ORTHOTIC AND PROSTHETIC DEVICE you are applying for? (required)

    27. If the insurance company pays you or the company who is providing the ORTHOTIC AND PROSTHETIC DEVICE, more than listed above, we ask that you inform ASF about this amount paid, once the insurance company processes the final claim. Do you agree to inform us? (required)

    28. What is your yearly deductible?, Has it been met? (required)

    29. Are you willing to provide a ASF patient testimonial after you start treatment?

      Please describe your hardship, by outlining your main points from the letter, using one sentence per point (maximum of 5 bullet points and or 5 sentences).