Prosthetics: management review lower extremity form


For prosthetists and orthotists – use this form, when requested by us, to review your client’s prosthetic management and measure progress against the predicted outcomes that were specified in the initial Prosthetic Treatment Request Form. This form is specifically for clients who have a lower extremity prosthetic device.

For help completing this form, see the separate notes document.

Coronavirus update

The TAC is unable to send or receive hard copy documents at this time. Please email forms or other documents to and include the client's claim number in the subject line.