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 ($625)
Ustep Junior ($625)
Ustep Tall ($665)
Ustep Platform Tall ($834)
Ustep Platform Small ($834)
Ustep PDL Standard ($655)
Ustep PDL Junior ($655)
Ustep PDR Standard ($655)
Ustep PDR Junior ($655)
Cane Standard ($209)
Cane Standard Tip ($209)
Cane Short ($209)
Cane Short Tip ($209)
Green Laser Cane ($229)
LaserCue ($199)
LaserCue with Cane ($209)
Platform Arm Attachment Tall ($209)
Platform Arm Attachment Small ($209)
Press Down Left Handles ($30)
Press Down Right Handles ($30)
Tall Handles ($45)
Accessory - Laser
No Laser
Red Laser ($259)
Green Laser ($279)
Accessory - Caddy
No Caddy
Caddy ($59)
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
$60
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
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