Standard drug special authorization request for plans administered by ClaimSecure.
- Completed by
- Physician
- Issued by
- ClaimSecure
- Format
- Fillable PDF
- Language
- English
ClaimSecure Custom Knee Brace Form (2002000-029A-CL)
ClaimSecure asks for this questionnaire when a plan member submits an estimate for a custom knee brace, so the request is assessed before approval. The physician describes the clinical condition, range of motion and the circumstances, such as surgery, that make a brace necessary, and ClaimSecure notifies the claimant in writing about plan coverage once everything has been assessed.
Who completes it
The prescribing physician signs Part 3 and completes Part 4 (current medical information) in full. The claimant completes Parts 1 and 2 and signs the authorization, and the supplier completes Part 5 with purchase details.
Submitting and payment
- How to submit it
- The completed form is returned to ClaimSecure with the estimate and supporting documentation by mail, fax or email, without stapling or taping receipts to it.
Good to know
- ClaimSecure's custom knee brace benefit is supplemental to provincial assistive devices programs, so the claimant should check provincial eligibility before applying.
- Part 4 asks how many hours per day and how frequently the brace is to be worn, and what type of activity it is required for.
- The form notes that it is not required for residents of Quebec.
- All fields should be completed in pen using blue ink, and the supplier attaches a breakdown of costs and any provincial plan application.
Get the official form
Download the current version from the source each time; forms change without notice.
Custom Knee Brace Questionnaire
Fill it with Vero
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Is the ClaimSecure custom knee brace form required in Quebec?
No. The instructions state that completion of the form is not required for residents of Quebec. Elsewhere, ClaimSecure asks for the questionnaire when a custom knee brace estimate is submitted, and all required information must be complete before approval.
What does the physician complete on the ClaimSecure knee brace form?
The prescribing physician signs Part 3 and completes Part 4 in full: the detailed clinical condition, prognosis, range of motion and limitations or articulation of the limb, the circumstances such as surgery that necessitate the brace and their date of onset, and how long and for what activity the brace will be worn.
Does ClaimSecure cover a knee brace already funded by the province?
ClaimSecure's benefit is supplemental to services available through the provincial assistive devices program. The claimant must indicate whether part of the cost will be covered provincially and explain why if not, and the supplier attaches a copy of the provincial plan application if applicable.