Prosthetics: treatment request form


For prosthetists and orthotists – use this form to request prosthetic treatment, new prosthetic devices, major repairs and changes of prescription. You will need to provide details of the proposed prothesis prescription and information to support the requested services and hours.

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.