Physician Prosthetic Assessment 2026

1. Click ‘Get Form’ to open the Physician Prosthetic Assessment in the editor.
2. Begin by entering the patient information, including Name, Sex, DOB, Height, and Weight. Ensure accuracy for effective assessment.
3. In the Medical Necessity section, indicate if there is any comorbidity affecting mobility. Provide explanations where necessary and check the appropriate boxes regarding the patient's ability to function with a prosthesis.
4. For Desire to Function with a Prosthesis, describe how the patient has communicated their desire for a prosthesis.
5. In Ability to Function with a Prosthesis, check all mobility aids currently used by the patient and describe their potential ability to function with a prosthesis.
6. Fill out Current and Expected Functional Level by selecting K Levels that best represent the patient's capabilities and provide explanations if they differ.
7. Complete the Multi-Discipline Corroboration section by checking relevant healthcare professionals consulted during assessment.
8. Finally, print your name, sign, and date at the bottom of the form before saving or sharing it directly from our platform.

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