Healthcare Prosthetics Fabrication Form

HEALTHCARE PROSTHETICS FABRICATION FORM

This Prosthetics Fabrication Form documents the prescription, specifications, and patient authorization for fabrication of a prosthetic device. The patient or legally authorized representative must complete all applicable sections, acknowledge the statements below, and provide an original signature authorizing fabrication and disclosure of protected health information to third-party manufacturers as necessary to complete the device.

Patient Information

Patient Name:

Date of Birth:    Gender: Male   Female   Other

Emergency Contact

Insurance Information

Medical History

Prescription and Device Specifications

Prescribing Provider:    Prescription Date:

Transtibial (below knee)   Transfemoral (above knee)   Transradial (below elbow)   Transhumeral (above elbow)

Laterality: Right   Left   Bilateral

Measurements, Imaging & Fabrication Method

Measurement/Cast Date:    Technician:

Manual cast   Digital 3D scan   Other

Materials, Components & Cosmetic Preferences

Foot/Ankle:

Terminal Device / Hand:

Standard finish   Custom color:

Special Instructions & Clinical Considerations

Estimated Cost & Financial Responsibility

Estimated Fabrication Cost (includes components and labor): $

Insurance   Patient/Guarantor   Other:

I authorize assignment of benefits to the prosthetics provider where allowed and understand that I am financially responsible for any charges not covered by my insurer, including but not limited to deductibles, co-insurance, and non-covered items.

Authorization, Consent and Release

By signing below I authorize fabrication of the prosthetic device as prescribed. I understand and agree that:

1. Fabrication will proceed in accordance with the prescription and specifications provided by the prescribing provider and the prosthetist; minor modifications necessary to achieve fit and safety may be made by the prosthetist.
2. I authorize release of my protected health information (PHI) necessary for fabrication, fitting, billing, and warranty services to third-party manufacturers, vendors, and payers involved in the fabrication process.
3. I accept that fit, comfort, and function may require adjustments after initial delivery and that follow-up appointments are my responsibility to schedule and attend.
4. The provider and manufacturers will use reasonable care in fabrication; however, there are inherent risks including skin irritation, pressure injuries, device malfunction, or need for replacement. I release the provider and manufacturer from liability for ordinary wear and agreed exceptions, except in instances of gross negligence or willful misconduct.
5. Title to the device may remain with the provider or manufacturer until payment in full is received when applicable, and I remain responsible for returned or uncollected items according to facility policy.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the facility's privacy practices describing how my protected health information may be used and disclosed for treatment, payment, and healthcare operations. I consent to the uses and disclosures necessary to facilitate fabrication, measurement, delivery, billing, and warranty claims.

Check to acknowledge: I acknowledge and consent to the above HIPAA disclosures and uses.

Patient / Guardian Certification

By signing below I certify that I have read and understand the information on this form, that the information I have provided is true and accurate to the best of my knowledge, and that I have had the opportunity to ask questions about the fabrication process, materials, anticipated outcomes, and financial obligations.

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