This form is to be used for requesting prior financial approval to provide orthotic services to eligible veterans, war widow/ers and
dependents. Specifically, the form is for seeking approval to provide:
orthotic services above financial and quantity limits listed in the Orthotists Schedule of Fees; and
item numbers that require prior financial authorisation listed in the Orthotists Schedule of Fees, such as custom orthoses.
If you are using an Apple computer and want to fill out your form electronically, please download the form and open it with Acrobat 7 or later.