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Manitoba Blue Cross Orthotics and Orthopedic Shoes Form

Manitoba Blue Cross uses one form for both pre-authorization and claims for custom orthotics, orthopedic shoes and shoe modifications. The medical prescriber supplies a specific diagnosis, the footwear required and whether it is for sports only, while the dispensing professional documents how the shoes or orthotics were made, the charges and their own certification.

Who completes it

The medical prescriber must complete the Prescription and Diagnosis section and sign it with their professional designation. The dispensing professional, such as a pedorthist or orthotist, completes the shoe, orthotics, charges and provider sections, and the service recipient completes their information, assignment of benefits and consent.

Submitting and payment

How to submit it
The form is marked as either a pre-authorization or a claim, and if payment is to go to the member rather than the provider of service, a paid receipt must be attached.

Good to know

  • The prescriber's diagnosis must be specific, and the prescriber indicates whether shoes, orthotics or both are required and whether the items are for sports purposes only.
  • Custom-made orthotics must be fabricated from raw materials, and the dispenser identifies the casting technique: foam casting box, plaster of paris slipper cast, 3D contact digitizing or 3D laser scanning.
  • For custom-made orthopedic shoes, the dispenser includes a copy of the detailed lab invoice; for prefabricated shoes, the name of the shoes and the modifications made.
  • If any expense results from an accident, the service recipient indicates whether it happened at work, in a vehicle or elsewhere.

Get the official form

Download the current version from the source each time; forms change without notice.

Orthotics, Orthopedic Shoes, and Modifications Claim Form

Official pagePDF

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.

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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.

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Frequently asked questions

Who completes the Manitoba Blue Cross orthotics claim form, the prescriber or the dispenser?

Both. The Prescription and Diagnosis section must be completed by the medical prescriber, who gives the diagnosis, footwear required and sports-only status and signs with their designation. The dispensing professional completes the orthopedic shoes or custom orthotics sections, lists charges and certifies the treatment was performed by them.

Can the same form be used for pre-authorization and claims?

Yes. A checkbox at the top of the form marks it as either a pre-authorization or a claim. The assignment of benefits section then asks whether payment goes to the provider of service; if payment is to be made to the member, a paid receipt must be attached.

What counts as custom-made orthotics on the Manitoba Blue Cross form?

The form distinguishes stock orthotics from custom-made orthotics fabricated from raw materials. For custom-made orthotics, the dispensing professional must identify the casting technique: semi-weight bearing foam casting box, plaster of paris slipper cast, 3D contact digitizing, 3D laser imaging scanning or another specified method.