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Prescription and Letter of Medical Necessity For Orthotic Prosthetic and Pedorthic Services Date Patient s Name SureStep De-rotation Strap Diagnosis /ICD-9 Expected Length of Need Indefinite Effective Date of Prescription Medical Reason for need Medically necessary to reduce mild internal/external deviations of the lower extremity throughout the gait cycle through the use of dynamic torsion straps which allow freedom of movement but encourage correct positioning in the transverse plane.
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The patient's name is the name of the individual receiving medical care.
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Patients' names should be filled out accurately and completely on medical forms or records.
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The purpose of the patient's name is to uniquely identify the individual receiving medical treatment.
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Information such as first name, last name, date of birth, and any other identifying details should be reported on patients' names.
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