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Application and Checklist for PAC HOPES Coding Verification Request Orthotics Instructions for Completing HOPES Coding Verification Application The PAC will only accept one application for each base

Complete and submit the HOPES Coded Verification Application in .DOC file format on a PC with a printer and a web browser, then print the following to your computer: Instructions for the PAC to Verify HOPES Coding Verification Request Request for PAC HOPES Coded Verification Form HOPES Coded Verification Documentation in DOC File Format HOPES Coded Verification Document Template Instructions for Completing HOPES Coded Verification Form The PAC will only accept one application for each base HOPES code being requested. Additional HOPES code(s) may be included on an application when they are add-on and/or accessory code(s) to the base code(s). If the PAC receives an application that does not follow these guidelines, the application will be returned as incomplete. Your HOPES Coded Verification Form must include the following: HOPES Code (each HOPES Code is listed on the HOPES Coded Verification Form below) HOPES Coded Verification Form Verification Code Verification Code Information to be Provided. Please make sure you are sure in supplying the correct verification code information at time of verification. When verification is requested you will be required to submit a verified response, with additional information. (For verification request codes listed below: HOPES code(s) will be entered on the HOPES Verification Form Verification Code will be entered in the box in the upper right-hand portion of the HOPES Coded Verification Form. Information to be provided to verify: (Please submit response to verification request listed below) This verification request from the PAC includes: HOPES Coded Verification Form HOPES Verification Package Verification Method (email or printed response) Verification File Verifying email address Verifying printed address Verifying phone number Verifying postal code Additional Information, if requested (i.e. additional fields if requested) Please ensure that the information and/or responses to the HOPES verification questions is completed as directed and accurately and fully respond to the questions on the form that is provided. If you are unable to provide a response to question 1 or 4 in the “Additional Information” section of this form, do not attempt to respond to the remaining questions/answers.

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