U Step Order Form Patient Information First Name Last Name Email* Patient Phone Number Street Address City State ZIP Patient Height Patient Weight Patient Diagnosis Alternate Contact Info Alternate Contact Name Alternate Contact Relation Alternate Contact Phone Items Ordered Item Ustep Standard ($595) Ustep Junior ($595) Ustep Tall ($630) Ustep Platform Tall ($794) Ustep Platform Small ($794) Ustep PDL Standard ($615) Ustep PDL Junior ($615) Ustep PDR Standard ($615) Ustep PDR Junior ($615) Cane Standard ($199) Cane Standard Tip ($209) Cane Short ($199) Cane Short Tip ($209) Green Laser Cane ($219) LaserCue ($189) LaserCue with Cane ($209) Platform Arm Attachment Tall ($199) Platform Arm Attachment Small ($199) Press Down Left Handles ($20) Press Down Right Handles ($20) Tall Handles ($35) Accessory – Laser No Laser Red Laser ($249) Green Laser ($269) Accessory – Caddy No Caddy Caddy ($49) Additional Order Notes Insurance Information D.O.B. (MM/DD/YYYY) Medicare Number Additional Insurance Info Other Insurance Primary Secondary Insurance Name Insurance ID # Payer ID Group # Address for Insurance Insurance Phone # Rx MD Info Rx MD Name Rx MD NPI # Rx MD Phone Rx MD Fax Medicare Info & Questions Prior Walker Yes No Wheelchair Yes No Skilled Care Yes No Prescription Option In-Step has prescription Customer is faxing Physician’s office is faxing Customer is scanning and e-mailing Customer is mailing it In-Step is requesting it No need – cash sale Other Notes on Eligibility Patient or caregiver advised about reimbursement, setup, and warranty (U2S: 3 yrs base, 1yr parts, LC: 3m, LQ: 6m). Yes No Patient or caregiver advised about how to contact us in the event of a concern or emergency. Yes No Client has been informed of the Medicare Reimbursement Policy Yes No Shipping Information Shipping Cost $0 $10 $15 $20 $30 $40 $50 Shipping Info / Patient Info Same as Patient Info Different Shipping Address Shipping Name Shipping Street Address Shipping City Shipping State Shipping ZIP Shipping Phone Number Bill To Address Billing Info / Patient Info Same as Patient Info Different Billing Address Billing Name Billing Street Address Billing City Billing State Billing ZIP Billing Phone # Payment Information Payment Receipt Credit info in office Credit info will be called in Sending Check Discount 10% 15% 20% Referral Information Name of Referrer Referral Center Order Notes Missing Information/Understanding/Internal Notes Submit Order and Mark if Complete Completed Order Yes No Submit Marketing by ActiveCampaign
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