Script:

Hello my name is _______ from __________, I'm giving you a call back in response to your request to confirm your
eligibility and I just need to verify your insurance and get you approved to receive your brand new braces right
away. So (PT NAME ) please know that this call is being recorded for quality assurance and training purposes. Now
(PT NAME) have you received any braces from Medicare within the last 5 years? (pt must not have received braces
requesting in the last five years)

Okay great, let me just verify some information please.

Gender:

DOB:

First and Last name (middle initial if given)

phone number

Address:(should be physical address)

Member ID:

Doctor's name:

Doctor's NPI:

Doctor's Address:

Doctor's phone number:

Doctor's Fax number:

So can you please tell me a little bit about your situation....

Where is your pain located? (Back, knees, shoulder, wrists or ankles)

TO GET THEM TO TALK ABOUT AREAS OF PAIN TRY THIS...

A lot of my patients say that pain will radiate and cause stiffness or discomfort, or sometimes stiffness may cause
you to compensate and move differently which may cause pain or discomfort in other areas. How do your Back,
Knee(s), Shoulder(s), Wrist(s) and Ankles feel in the morning or at the end of the day?
So we can make sure to get the correct sizes for your support system(s) let me verify a few more things.

Height:

Weight:

Waist size:

Shoe size:

Major Medical Conditions:

Cause of Pain:

Level of pain (on worst day):

How long have you been experiencing pain?

Frequency of pain:

Describe the pain:

Pain symptoms:(muscle weakness, muscle spasms, instability, aching, difficulty moving, difficulty walking, difficulty
lifting)

What makes the pain worse?

Treatments tried:

Have you seen a doctor int he last year?

Any surgeries int he last 5 years?

Summary Must Be Read Verbatim

Okay ____________ do I have your permission to record a brief summary of the information we have just
discussed to share with the Doctor who will be reviewing your medical information? (CLEAR YES)

Today's date is _________.....Please state your first and last name for the recording, please state your date of birth
for the recording .What is your current address?

We spoke about a support system for your back...Correct? (Must Be Clear Yes)

We spoke about a support system for your Shoulder...Correct? (Must Be Clear Yes)
We spoke about a support system for your Knee(s)...Correct? (Must Be Clear Yes)

We spoke about a support system for your Wrist(s)...Correct? (Must Be Clear Yes)

We spoke about a support system for your Ankle(s)...Correct? (Must Be Clear Yes)

Do we have permission to reach out to your doctor to discuss your medical history?

Pain Cream:

Do you want pain cream as well for your pain? ( It will not cost to you, It will be covered in your health insurance)

Do you have any skin allergies? ( If YES)

We are sending you Anti-Fungal Cream used to treat a variety of fungal skin infections(It will not cost to you, It will
be covered in your health insurance)

(PATIENT NAME) if the Doctor does prescribe these items after reviewing your medical intake information, you will
have the freedom to direct these orders to a (DME SUPPLIER) of your choice.If you would like we can have one of
the participating (DME SUPPLIERS) either Family Medical or Cardinal Care deliver your items right to your door via
mail order. Would you like us to deliver them to your door? (MUST BE CLEAR YES)

If the doctor needs to call to verify any information what is the best time of day to call...morning, afternoon or
evening? You will receive a call back within the next 24 to 48 hours from our shipping department as well to verify
you mailing information so please make sure to answer the phone.

Best Time To Call*

Morning

Afternoon

Evening

Thank you for your time it has been a pleasure speaking to you, I hope you have a nice day.