Podiatry Orthotic Claim letter

Chief Complaint

[specific medical condition or diagnosis]

Template

Date of service: ATTENTION: Claims Department To Whom It May Concern, Re: Patient: [patient's full name] Date of Birth: [patient's date of birth] This patient suffers from [patient's diagnosis]. He/She would greatly benefit from a new pair of custom-made orthotics. These devices are made from three dimensional laser scans in a neutral subtalar joint, non-weight bearing position. Custom-made orthotics are a medical necessity and are to be worn at all times. The total case fee for orthotics is $[total case fee]. Breakdown of fees: • Podiatry visit - $[podiatry visit fee] • Biomechanical Exam/3D Scanning Total for podiatry fees: - $[biomechanical exam fee] • Custom-made orthotics -$[custom-made orthotics fee] If you need any further information, please do not hesitate to contact us. Sincerely, Alan D. Boroditsky, B.Sc. D.P.M. MSP #: 60082