Form Hfs2305m "Knee Brace Questionnaire" - Illinois

Form HFS2305M is a Illinois Department of Healthcare and Family Services form also known as the "Knee Brace Questionnaire". The latest edition of the form was released in February 1, 2015 and is available for digital filing.

Download an up-to-date Form HFS2305M in PDF-format down below or look it up on the Illinois Department of Healthcare and Family Services Forms website.

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State of Illinois
Department of Healthcare and Family Services
Knee Brace Questionnaire
Patient Name:
DOB:
RIN:
Patient Height:
Weight:
Select One: Left
Right
Bilateral
Applicable Diagnosis:
Date of onset/injury:
Purpose of Device:
State Medical Necessity:
Previous Procedures/Surgeries Date and Type:
If requesting a custom knee orthosis, explain why a prefabricated knee orthotic or custom fitted orthotic cannot be
considered over a custom fabricated knee orthotic:
Product information:
Attach the following information and a completed HFS 1409, Prior Approval Request Form and practitioner order with
the questionnaire:
• Copy of measurements for custom fittings must be submitted with the request.
• Manufacturer name and acquisition cost with a copy of invoice must be submitted with this request.
Practitioner's Signature with degree:
Date
Office Phone #:
Fax:
NPI:
HFS 2305M (N-2-15)
Page 1 of 1
State of Illinois
Department of Healthcare and Family Services
Knee Brace Questionnaire
Patient Name:
DOB:
RIN:
Patient Height:
Weight:
Select One: Left
Right
Bilateral
Applicable Diagnosis:
Date of onset/injury:
Purpose of Device:
State Medical Necessity:
Previous Procedures/Surgeries Date and Type:
If requesting a custom knee orthosis, explain why a prefabricated knee orthotic or custom fitted orthotic cannot be
considered over a custom fabricated knee orthotic:
Product information:
Attach the following information and a completed HFS 1409, Prior Approval Request Form and practitioner order with
the questionnaire:
• Copy of measurements for custom fittings must be submitted with the request.
• Manufacturer name and acquisition cost with a copy of invoice must be submitted with this request.
Practitioner's Signature with degree:
Date
Office Phone #:
Fax:
NPI:
HFS 2305M (N-2-15)
Page 1 of 1
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