Thanks for referring a patient to North Carolina Orthotics & Prosthetics.  Due to the breadth of paperwork and specific nature of patient record-keeping required for many Orthotics and Prosthetics patients, we have compiled a list of documents that should be beneficial to all referring physicians and their staff.

Patient Referral Form

The first document is a Patient Referral Form.  It maximizes efficiency in the referral process and is required for any patient being referred by a physician.  The image below is a link to open the document.  You may either complete and submit the paperwork electronically, or print the document and return via scanned email attachment.  You can find the email address for each office here.

If you choose to complete the paperwork electronically, please read the following carefully.  Most modern browsers (Chrome, Safari, etc.) will automatically open this document in a PDF viewer.  Please note that it will NOT be possible to electronically complete this document and submit via the default PDF viewer in your browser.  As a result, if you plan to electronically submit the Patient Referral Form, please follow these instructions:

  1. Click the image below to open the Patient Referral Form in your browser’s PDF viewer.
  2. Follow prompts within the viewer to save the PDF document to a file directory on your computer.
  3. Use the newest version of Adobe Acrobat Reader to open the document.
  4. Complete the form by providing requested information in each field.
  5. When finished, select the Submit button associated with the appropriate NCOPI office location.
  6. Follow instructions provided by Adobe Acrobat Reader to deliver the completed document via email attachment.

If you choose to print the form and complete in writing, please scan the completed form and return via email.  Please include the subject line referring physician <Physician Name> – <Patient Name>.



The following are additional forms and guidelines that will be helpful in preparing patient records.  If you have questions, or if we can be of further assistance, do not hesitate ask.

Flip Card for Referring Physicians

Face to Face High Cost DME

For certain specified items of durable medical equipment the Affordable Care Act requires that an in-person face-to-face examination documenting the need for the item must have occurred sometime during the six (6) months prior to the order for the item. The purpose of this letter is to provide a summary of these requirements.

Medicare Documentation Requirements

It is your responsibility as the ordering physician to determine and document the medical need for all healthcare services.  The purpose of this letter from the Centers for Medicare & Medicaid Services is to outline your responsibility in documenting these needs.

Therapeutic Shoe Requirements

This document from the Centers for Medicare and Medicaid Services details criteria that must be met in order for diabetic patients to receive shoe and insert benefits from Medicare.

Diabetic Shoes Checklist

This checklist will help you meet all of the criteria set forth by Medicare to ensure that our mutual patient will receive their Diabetic Shoes and Inserts benefits.

Diabetic Foot Exam Clinical Notes

Please use this form to notate the foot condition of our mutual diabetic patient.

Prosthetic Assessment

Please complete this form and use as a guide to dictate your medical records for our mutual patient. This form will help you to meet the criteria set forth by Medicare so that our mutual patient receives their benefits for DME.

Artificial Limb Documentation Letter

This letter from the Centers for Medicare and Medicaid Services presents guidelines for documenting functional capabilities of patients, which should be met in order to insure that our mutual patient receives both care and equipment best suited to them.