{"id":3628,"date":"2026-06-18T16:29:20","date_gmt":"2026-06-18T21:29:20","guid":{"rendered":"https:\/\/dmeplususa.com\/?page_id=3628"},"modified":"2026-06-18T16:30:53","modified_gmt":"2026-06-18T21:30:53","slug":"request-custom-brace","status":"publish","type":"page","link":"https:\/\/dmeplususa.com\/pt\/request-custom-brace\/","title":{"rendered":"Request Custom Brace"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3628\" class=\"elementor elementor-3628\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-07944e4 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"07944e4\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-649f5aa\" data-id=\"649f5aa\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-6ed56f1 elementor-section-height-min-height elementor-section-boxed elementor-section-height-default\" data-id=\"6ed56f1\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-a5f6c00\" data-id=\"a5f6c00\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-7544220 elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"7544220\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeInLeft&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Custom orthotic\/Prosthetic Request Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-8244c69 elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"8244c69\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeInLeft&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\"> For the states Of NY, NJ &amp; Eastern PA\n\n\n\n\n\n\n<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-5c3f2a7\" data-id=\"5c3f2a7\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-7db0116 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"7db0116\" data-element_type=\"section\" data-e-type=\"section\" id=\"form\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-5708969\" data-id=\"5708969\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-d293847 elementor-widget elementor-widget-shortcode\" data-id=\"d293847\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>window.enableEventObserver=true<\/script>\n<script>window.enableDateFieldSelectInputs=false<\/script>\n<script>window.CDN=\"https:\/\/cdn.jotfor.ms\/\"<\/script>\n<script>window.umdRootPath=\"https:\/\/cdn.jotfor.ms\/s\/umd\/a0da8db76e2\/\"<\/script>\n<script>window.staticRootPath=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/\"<\/script>\n<!--[if lt IE 9]>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/js\/vendor\/flashcanvas.js\" type=\"text\/javascript\"><\/script>\n<![endif]-->\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/js\/vendor\/jquery-3.7.1.min.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/js\/vendor\/jSignature\/jSignature.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/js\/vendor\/jSignature\/jSignature.CompressorBase30.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/js\/vendor\/jSignature\/jSignature.CompressorSVG.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/js\/vendor\/jSignature\/jSignature.UndoButton.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/js\/vendor\/jotform.signaturepad.new.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/static\/prototype.forms.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/static\/jotform.forms.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/js\/vendor\/maskedinput_5.0.9.min.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/js\/vendor\/imageinfo.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/file-uploader\/fileuploader.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/umd\/a0da8db76e2\/for-signature.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/js\/payments\/paymentUtils.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/js\/payments\/validategateways.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/s\/umd\/a0da8db76e2\/for-aria-notify-polyfill.js\" type=\"text\/javascript\"><\/script>\n<script>window.allTranslations = {\"acceptLanguage\":\"en-US,en;q=0.9\",\"cardFormTexts\":[\"{number} Questions\",\"{number} Question\",\"Questions\",\"Question\",\"Send Verification Code\",\"See All\",\"Go Back\",\"Your form is saved successfully!\",\"Please enter a valid email address.\",\"Something went wrong while saving your answers. 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It will be completed when you submit the form.\"],\"langs\":{\"en\":\"en-US\",\"es\":\"es-ES\",\"fr\":\"fr-FR\",\"it\":\"it-IT\",\"pt\":\"pt-PT\",\"de\":\"de-DE\",\"tr\":\"tr-TR\",\"ca\":\"ca-ES\",\"nl\":\"nl-NL\",\"sv\":\"sv-SE\",\"hu\":\"hu-HU\",\"nb\":\"no-NO\",\"nn\":\"no-NO\",\"no\":\"no-NO\",\"da\":\"da-DA\",\"ro\":\"ro-RO\",\"fi\":\"fi-FI\",\"pl\":\"pl-PL\",\"ru\":\"ru-RU\",\"zh\":\"zh-CN\",\"zb\":\"zb-ZB\"},\"languages\":{\"English (US)\":\"en\",\"English 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America)\":\"es-419\",\"Sundanese\":\"su\",\"Swahili\":\"sw\",\"Tajik\":\"tg\",\"Tamil\":\"ta\",\"Tatar\":\"tt\",\"Telugu\":\"te\",\"Thai\":\"th\",\"Tigrinya\":\"ti\",\"Tonga\":\"to\",\"Turkmen\":\"tk\",\"Twi\":\"tw\",\"Uighur\":\"ug\",\"Ukrainian\":\"uk\",\"Urdu\":\"ur\",\"Uzbek\":\"uz\",\"Vietnamese\":\"vi\",\"Welsh (Cymraeg)\":\"cy\",\"Western Frisian\":\"fy\",\"Xhosa\":\"xh\",\"Yiddish\":\"yi\",\"Yoruba\":\"yo\",\"Zulu\":\"zu\",\"en\":\"English (US)\",\"en-UK\":\"English (UK)\"},\"translations\":{\"en\":{\"03727ac48595a24daed975559c944a44\":\"Day\",\"7cbb885aa1164b390a0bc050a64e1812\":\"Month\",\"537c66b24ef5c83b7382cdc3f34885f2\":\"Year\",\"77587239bf4c54ea493c7033e1dbf636\":\"Last Name\",\"b55e509c697e4cca0e1d160a7806698f\":\"Hour\",\"f670ea66cfb0e90bd6090472ad692694\":\"Minutes\",\"44749712dbec183e983dcd78a7736c41\":\"Date\",\"86f5978d9b80124f509bdb71786e929e\":\"January\",\"659e59f062c75f81259d22786d6c44aa\":\"February\",\"fa3e5edac607a88d8fd7ecb9d6d67424\":\"March\",\"3fcf026bbfffb63fb24b8de9d0446949\":\"April\",\"195fbb57ffe7449796d23466085ce6d8\":\"May\",\"688937ccaf2a2b0c45a1c9bbba09698d\":\"June\",\"1b539f6f34e8503c97f6d3421346b63c\":\"July\",\"41ba70891fb6f39327d8ccb9b1dafb84\":\"August\",\"cc5d90569e1c8313c2b1c2aab1401174\":\"September\",\"eca60ae8611369fe28a02e2ab8c5d12e\":\"October\",\"7e823b37564da492ca1629b4732289a8\":\"November\",\"82331503174acbae012b2004f6431fa5\":\"December\",\"9d1a0949c39e66a0cd65240bc0ac9177\":\"Sunday\",\"6f8522e0610541f1ef215a22ffa66ff6\":\"Monday\",\"5792315f09a5d54fb7e3d066672b507f\":\"Tuesday\",\"796c163589f295373e171842f37265d5\":\"Wednesday\",\"78ae6f0cd191d25147e252dc54768238\":\"Thursday\",\"c33b138a163847cdb6caeeb7c9a126b4\":\"Friday\",\"8b7051187b9191cdcdae6ed5a10e5adc\":\"Saturday\",\"1dd1c5fb7f25cd41b291d43a89e3aefd\":\"Today\",\"262f85cc9967ff615cfa8de8e2d125f8\":\"MM-DD-YYYY\",\"36b73593da5406af97c429f664eb6332\":\"Patient Information\",\"cd5cd8a39e92552fa43dca6324aef32a\":\"FACILITY NAME\u00a0\",\"fc99f88eb029b1fa3cd14c6a8ca0061f\":\"What facility is the patient in?\",\"4c5dc58bb707f5f4c831914cb5e92bb0\":\"FACILITY ADDRESS\",\"aaff974958972c1d45d45cb3b77bff79\":\"Street Address\",\"859214628431995197c0558f7b5f8ffc\":\"CITY\",\"2b848a8cc886d253d21a77c43cd50aae\":\"STATE\",\"b532e61fef0cc04229e010f3c1e3e5a8\":\"ZIP CODE\",\"27aabafac1b42179a3c1537c6a2b768e\":\"REQUESTER (DOR\\u002FPT\\u002FOT\\u002FOTHER) NAME\",\"88c61c78e9e92a44bb5e12ab83ed3649\":\"REQUESTER EMAIL ADDRESS \",\"605aca88cbf739a4a77f5f794f36039d\":\"PATIENT NAME\",\"f180ec16a8d349cb27b856e9200f0ac1\":\"PATIENT DOB\",\"6b19fc3d5e07bf4051873e59b536ce85\":\"Browse Files\",\"51bc8d15c47c29a52cf0f127892292fb\":\"UPLOAD FACESHEET \",\"aa490ec205bac9c023ce8aee37651d9d\":\"UPLOAD THERAPY NOTES\",\"69a84ceaa572329d0cf1373893bc2dc3\":\"REHAB PAYER SOURCE\",\"62ed6e263b9ee93bd505920610e3741b\":\"Med A\",\"a769e63a9c7d45e9462ea664e646a45e\":\"Med B\",\"6311ae17c1ee52b36e68aaf4ad066387\":\"Other\",\"413ca24685778e90f3f4a791a3f0982e\":\"DATE OF MED A DC\",\"db5f8114a8102abb627a9def7510d85d\":\"DATE OF DC TO HOME\",\"60d65769e17d580b4cc077b24ba2b1dd\":\"Item Information\",\"7a716b2464586cd61f0391ff35441377\":\"CONDITION BRACE IS TREATING\",\"dd48d539beb24d72c2e9de83ad30a21e\":\"M24.50 Contracture, unspecified joint.\",\"cf1ace97bac7203fadac7a91743eeaf3\":\"M24.51 Contracture, shoulder.\",\"7c8aaae0bf08fda2fbac40087167b10e\":\"M24.52 Contracture, elbow.\",\"254c29b245a4c5d8c25ef0117162f06d\":\"M24.53 Contracture, wrist.\",\"e31bd687209fcafa8a5fabea241f7fe0\":\"M24.54 Contracture, hand.\",\"dacce421290b51f9689aafb0384905db\":\"M24.55 Contracture, hip.\",\"c75065f6f2eee27ca477c7538d9af245\":\"M24.56 Contracture, knee.\",\"51c35571d23eb6fe30b1a3a093aed756\":\"M24.57 Contracture, ankle & foot.\",\"31c0b8e52060dc10c276152b692c1f4d\":\"Other.\",\"3569a4e76b94b20ef0ab338fa87ec981\":\"Please Select\",\"13348442cc6a27032d2b4aa28b75a5d3\":\"Search\",\"b72a4094a330461ea627ec0b2a9198fd\":\"PROM OF JOINT BY GONIOMETER\",\"1ab1b3b6ebf29a02b24fa268ec5079dc\":\"SPECIAL REQUESTS\",\"a9fe45fababefffacd95c97a12f687b8\":\"TREATING PROVIDER DO\\u002FMD\\u002FPA\\u002FNP EMAIL ADDRESS\",\"03036b7142fa2a23757d65dcd9e42b42\":\"Expand Here to Select Your Products\",\"b5a7adde1af5c87d7fd797b6245c2a39\":\"Description\",\"3601146c4e948c32b6424d2c0a7f0118\":\"Price\",\"1ea52fcfd59d54eb0c87e256c536acfb\":\"Item subtotal:\",\"de149bc98951110dea367be75b9f6a50\":\"Flex Hand Grip Resting Hand Spint\",\"a0488b67730d5ed8a700be795c4a7bc9\":\"Includes sized cones that allow a gradual increase of the hand\\u002Ffinger\u2019s range of motion L3809\",\"694e8d1f2ee056f98ee488bdc4982d73\":\"Quantity\",\"a1fa27779242b4902f7ae3bdd5c6d508\":\"Type\",\"f13239c9f828b691624fd47943d209fa\":\"Left with Regular Cones\",\"1eab19c71c13f875a2d08ee3af91358a\":\"Left with Reverse Cones\",\"63d580b8bba52e7196281042522e22cf\":\"Left with Cylinders\",\"385e853ea53df1312bc6565dede3ecb5\":\"Right with Regular Cones\",\"a6d75be80b40dd79ed456a8b5d81991a\":\"Right with Reverse Cones\",\"aedf0543112399019291d5ab2a593bd7\":\"Right with Cylinders\",\"bb2eb6b5b52ef5a4ae675c2c1f607578\":\"Functional Resting Hand Splint  \",\"f6907b753639d1fb80881eb67b43b5d0\":\"Moldable aluminum base. Used for moderate lost range including severe thumb adduction and thenar eminence collapse. Universal size fits most adults. L3809\",\"c142a73b77f3c3df40777af2651f4915\":\"Side\",\"945d5e233cf7d6240f6b783b36a374ff\":\"Left\",\"92b09c7c48c520c3c55e497875da437c\":\"Right\",\"f57272aa4140b009401373f4ae7ed35e\":\"Bilateral (Both)\",\"c15912496c14b1ba1779294199b736a6\":\"Prosperity Resting Hand Splint\",\"f10ca4f2084554babe9e1d618553d37a\":\"Slit between the 3rd & 4th digits to allow for varying degrees of range of motion of fingers. Perfect for Dupuytren\u2019s contracture. L3809\",\"c4c2157f1de8143ed2fa1d0e617af699\":\"Bilateral (both)\",\"6f6cb72d544962fa333e2e34ce64f719\":\"Size\",\"5dbc98dcc983a70728bd082d1a47546e\":\"S\",\"69691c7bdcc3ce6d5d8a1361f22d04ac\":\"M\",\"d20caec3b48a1eef164cb4ca81ba2587\":\"L\",\"4a29c36494ca4701f97faa79e8b118ec\":\"ThumbEase Resting Hand Splint\",\"ff5cba0e690400cee6cca05e238b00bd\":\"For severely adducted thumbs and thenar eminence collapse. Can be remolded to address mild to moderate lost range, and then gradually remold to continue restorative process as patient improves. L3809\",\"4e51ce89637824ccde8d4ee797b78151\":\"XS\",\"a7a4ccc5e1a068d87f4965e014329201\":\"XL\",\"32276ec3903e2487e71381be64dba2b6\":\"Restorative Elbow Splint\",\"576f1db695eade091005b3d2852928ec\":\"Provides prolonged low load passive stretch and treats flexion contractures of the elbow that result in lost range of motion. Adjustable dials allow gradual changes to move joint toward normal alignment. L3760\",\"28a339bc2d6ec01de46dfeb2fa9be168\":\"Restorative Elbow Splint With Air \",\"696dcb8ff2e4f3b7f12a5f15ae64608e\":\"rovides prolonged low load passive stretch and treats flexioncontractures of the elbow that result in lost range of motion. RestAir technology uses an air bladder at the inside of the elbow, positioned parallel to the arm to redistribute skin pressure. Bilateral hinged uprights work with the air bladders to continue to move the joint toward normal alignment. L3760\",\"965e542803558c4349b056a4280326b8\":\"Hyper-Extension Elbow Splint\",\"847a81df689f595baf9ce2ea2de9f90c\":\"Provides prolonged low load passive stretch to treat elbow hyperextension and\\u002For extensor tone that result in lost range of motion. L3760\",\"aeea36ce23bba2a1eb2cdd5c6c51dcca\":\"Kentucky Kollar\",\"fbb6ce1e20a44e932d3dd226920d2fac\":\"Treats conditions such as torticollis (wry neck) Adjustable strap at neck seats and secures the collar on the shoulder. Pad under the arm provides comfort and redistributes skin pressure. L0113\",\"1688a7560e841ae4912d9c0e60144f56\":\"3X-S\",\"9a2318a4ce886f188fd5014c21194b69\":\"2X-S\",\"f7a69dcb20acde7e6e5a83d676dc74df\":\"X-S\",\"d6873d6369c7bc5afb8fa4af37a6de12\":\"X-L\",\"8b84f243087b124382169639339e3c99\":\"Restorative Knee Brace\",\"1e8862e1a94643889eaa8633a7cac557\":\"Addresses mild to severe flexion contractures. Adjustable dials lock in to apply mild stretch. Side bars flex when patient draws inward, then brings the joint back to preset position. Gradually reset dials to work joint toward normal alignment and relenthen shortened tissue. L1831\",\"21a682b598f7337188161dfcce114f8b\":\"Restorative Knee Brace With Air\",\"a4021b7cffc8a789b0a81f04719152f3\":\"Addresses knee flexion contractures with air technology. RestAir technology uses 2 air bladders at the back of the leg to redistribute skin pressure. Bilateral hinged uprights work with the air bladders to continue to move the joint toward normal alignment. L1831\",\"2161c9852d458abaf3c2f2af874465e8\":\"Bilateral (2 Braces)\",\"fd4a897526887631284068216ed1e6a7\":\"Hyper-Extension Knee Brace\",\"8c919732efafd6d9cf2df2fb75abb254\":\"Provides prolonged low load passive stretch and treats hyper extension of the knee. L1831\",\"75e5a23a608dc0d830e16747f3d66136\":\"Hip Contracture Brace\",\"35438116e64062dea8694a0e74e92b91\":\"Comfortably and safely treats hip adduction & scissoring. RestAir technology uses 4 air bladders (2 on each side) to redistribute skin pressure and gradually increase the hip\u2019s range of motion. L1652\",\"dcb79a1d80da9db9f07facd9849544ce\":\"Multi Podus Boot\",\"386c549d0024f03a59edadf0bf6b91d5\":\"Helps maintain neutral alignment of the foot and to relieve pressure on the heel Flex Technology splint moves with the patient\u2019s abnormal muscle tone and spasticity for comfort and helps to relax the abnormal muscle tone L4397\",\"7641e5f4e7e8517bd0477fd81e3de1b8\":\"Universal\",\"9efddb59e375f8c2fc7a93e96252058d\":\"Restorative Flex Boot\",\"ff6a952df3ea1f2de4946988448c2d58\":\"Helps maintain neutral alignment of the foot and to relieve pressure on the heel Best for severe ankle\\u002Ffoot Contractures and foot drop. L4397\",\"b3a4418f5957f24a10137346c80c1e77\":\"Enter coupon\",\"9639e32cab248434a17ab32237cb3b71\":\"Apply\",\"4e62ebb4860d2ad9306eb37f49f454bc\":\"Coupon is valid.\",\"4992211fd9e0bff0177521e35bdb7e65\":\"Coupon is expired. Please try another one.\",\"3564c1e380e08922f1b370d3daef8074\":\"Coupon is invalid.\",\"4162143db7e342cc6518153772c13f19\":\"Please enter a coupon.\",\"ea9cf7e47ff33b2be14e6dd07cbcefc6\":\"Shipping\",\"96b0141273eabab320119c467cdcaf17\":\"Total\",\"2194aaec8cc7086ab0e93f74547e5f53\":\"Subtotal\",\"4b78ac8eb158840e9638a3aeb26c4a9d\":\"Tax\",\"8c38776925f7cf41c090646a43157024\":\"Categories:\",\"b1c94ca2fbc3e78fc30069c8d0f01680\":\"All\",\"059a1aa256b770eca2d69c096f759ad0\":\"Sort By\",\"41bdf5037622e9965944a98c52d7fce8\":\"Name: A to Z\",\"9f4dc7aa11bb648bb80275102dcadd5f\":\"Name: Z to A\",\"30c4bb9e31abf82c375aaed9e0e8dbf1\":\"Price: Low to High\",\"67cfed6f52d81c9a2cffcd71aa5e280c\":\"Price: High to Low\",\"1be673e5ee086fb7b29da57eeee173b4\":\"Clear Sort\",\"661c63002f934f042d972e9cc953483c\":\"FITB_31_template\",\"ee8f51e1a4172d0556932bb86bd7dd76\":\"Therapist Full Name\",\"d6dc8bc7bc3f0a50b7bf05fdec6926d5\":\"Patient Full Name\",\"591aa428a8e089e4f679aef4f2de0693\":\"I am requesting this brace based on my recommendations and diagnosis listed above. I will fit and adjust the brace, if needed, on behalf of DME Plus INC.\\u002FPharmacy\u00a0Plus or any of its affiliates.\",\"0e0ec279e118b60cfe9c6986fac96949\":\"text_41\",\"54b452ca352997e999901f4de2856627\":\"PATIENT SIGNATURE-DOR\\u002FOT\\u002FPT\\u002FPOA CAN SIGN ON PATIENTS BEHALF IF NEEDED. \",\"226f9780ed915d4b4d29c93a6b2116b7\":\"RELATIONSHIP (IF NOT CUSTOMER)\",\"a0bfb8e59e6c13fc8d990781f77694fe\":\"Continue\",\"5256bdbc07fc28984d010390ac16c288\":\"Clear All Questions\",\"13dba24862cf9128167a59100e154c8d\":\"Print\",\"c9cc8cce247e49bae79f15173ce97354\":\"Save\",\"9303c9bd4f8178680dc382adbfcd62af\":\"This field is required.\",\"dc92c5f03d709eca57e19b6d17197a02\":\"At least one field required.\",\"99201fd097b5aaeb3462ebc83eff7825\":\"Every row is required.\",\"f1b43179961ab51bfd5d499cf371c317\":\"Every cell is required.\",\"2129cfe1f2e9bb2bb7a5481099791221\":\"This field can only contain letters\",\"35406d5b61b361b89bf9607d905c4aef\":\"This field can only contain cyrillic characters\",\"10dc517c5a6d14b041dee8ab37183388\":\"This field can only contain a valid URL\",\"16e9d338633bd4fe82e22d95f13e5af8\":\"This field can only contain numeric values\",\"7da89e0a836e899bc127527ed74980a1\":\"This field can only contain letters and numbers.\",\"016391aa78e9d1f993314578722f121a\":\"This field can only contain currency values.\",\"8075bbc0f934e4512d37ebd0a1d9549a\":\"Field value must fill mask.\",\"af29e6db7d67c0f8c12251cba6c33cc7\":\"There are incomplete required fields. Please complete them.\",\"fb94d659e6e4038c318fa9b03cce4ae3\":\"File size cannot be bigger than:\",\"45e3d00e399daae4eea6f18c815a20e3\":\"File size cannot be smaller than:\",\"c5ee7f2b34c9aefd429bb80b1cbf3077\":\"Are you sure you want to clear the form\",\"597465271fb769eb8207d5a46e4ec2bc\":\"Your score should be less than or equal to\",\"c326dd8f7668e5710b75ff9375f3fd4c\":\"Enter a valid e-mail address\",\"6db53b6dcee140c816649643db877a13\":\"You need to validate this e-mail\",\"a8efdde75d2d73021649b3bbaeefcef6\":\"You can only upload following files:\",\"25e8f2fd2871c8423bbe4e254066cd98\":\"Please wait...\",\"35437b37dd14fbc3b3a79a288b23be2c\":\"E-mail does not match\",\"b2aab810c86e138362208b9a32912eac\":\"Sorry! Only one entry is allowed. \\u003Cbr\\u003E Multiple submissions are disabled for this form.\",\"cf5fd0f16dd79c85ac3767e345161443\":\"Score total should only be less than or equal to\",\"8ac19225616bae77084753d66979780a\":\"Input should not be less than the minimum value:\",\"98cd04d3875014592379f7bce7995fb2\":\"Input should not be greater than the maximum value:\",\"2d786e153c0c4862bec3ae3870574cc4\":\"The maximum digits allowed is\",\"329c4b66ab75002ccd63b4180f42c988\":\"Free email accounts are not allowed\",\"cd1a7e876be6e2effedd0e802023c671\":\"The minimum required number of selections is \",\"8d26aed94a35a69db69b7e2d6851a5ac\":\"The maximum number of selections allowed is \",\"b48787dc47f3b69b028917941337fd42\":\"The number of characters should not be less than the minimum value:\",\"b3d7929033fe1fb39f6532e933e880ee\":\"Date must not be in the past.\",\"1b2a41b0c99f5a094ec3516c5cf97f0b\":\"This date is unavailable.\",\"251814dc91cde028bc14124ac4820115\":\"This date is not valid. The date format is {format}\",\"49782692f55c0bd0a9989850d4cbf6a6\":\"This date is not valid. Enter a valid {element}.\",\"b24de2a71202e0f9c7b636359751828d\":\"You must be older than {minAge} years old to submit this form.\",\"dd7b56cdbe0b0b6cbfb8658ccb7a9a2f\":\"{file} has invalid extension. Only {extensions} are allowed.\",\"15a7bc0f2f5b41cf6513d601f313d886\":\"{file} is too large, maximum file size is {sizeLimit}.\",\"cb7bd46742cef5debea16cf3d48efc21\":\"{file} is too small, minimum file size is {minSizeLimit}.\",\"024bd26ebd8b593e393b06b750e9421d\":\"{file} is empty, please select files again without it.\",\"3fdeba4152839ff0304fd072308ae86a\":\"File upload failed, please remove it and upload the file again.\",\"ecbb571ebe46e3edf4fd6ce7ed83b30f\":\"The files are being uploaded, if you leave now the upload will be cancelled.\",\"8af32b0b0af249b2d4247ec51e72e127\":\"Only {fileLimit} file uploads allowed.\",\"400f698994607bfa7287e1c3b33b57a5\":\"Drag and drop files here\",\"92fbf0e5d97b8afd7e73126b52bdc4bb\":\"Choose a file\",\"24010235662f4eec0efa979593775d45\":\"Max. file size\",\"24875f0ed1fc6afeba67b00748321ad1\":\"There are errors on the form. Please fix them before continuing.\",\"b1cdc3262f2b7f3a5e788eefb67fb496\":\"There are errors on this page. Please fix them before continuing.\",\"4d4776d4b5c3ea0b7ce66de76701a7ec\":\"Too many words. The limit is\",\"0d55fa0301ec37e35a56482fced7eb92\":\"Too few words.  The minimum is\",\"16e1733cb31457a8e4b3cc470dcd34e9\":\"Too many Characters.  The limit is\",\"7afe0702c46046b2873cc496cac2151f\":\"Too few characters. The minimum is\",\"ad50d78b6787909d358efac6e6d21470\":\"Credit Card Number is invalid.\",\"b241f4c14c0cc2b1e3bdb3459ffa79a1\":\"CVC number is invalid.\",\"d5bea00110d578d55cea1609dfd4f8d5\":\"Expire date is invalid.\",\"7170fc9136e17665e1a52cff07182d62\":\"Please fill up the credit card details.\",\"97f014aa339f5b37951f100fb1a086d8\":\"Please select at least one product.\",\"54b2b7241a722e63682bcbfeb1683cf9\":\"Please enter numeric values for donation amount.\",\"7d33c2945c766b1440013b52cb16d039\":\"Please enter a whole number.\",\"46da021f90d09d35d4b8e46e97b0da92\":\"Minimum amount is {minAmount} {currency}\",\"dd1f775e443ff3b9a89270713580a51b\":\"Previous\",\"10ac3d04253ef7e1ddc73e6091c0cd55\":\"Next\",\"b078ffd28db767c502ac367053f6e0ac\":\"START\",\"a4d3b161ce1309df1c4e25df28694b7b\":\"Submit\",\"177faad38db25e3c50a8327ac8331914\":\"Review and Submit\",\"046ee781cd41da41104c5f1b38bd37d3\":\"Back to Form\",\"661cdd62ee19d1f4ebd82fafda356e3e\":\"See All\",\"8bf8854bebe108183caeb845c7676ae4\":\"of\",\"f2d880ce495ccc10b0fdcf87c0b57a96\":\"All fields marked with * are required and must be filled.\",\"d7bacae38602e3207d25eff48fee9024\":\"Selected Time\",\"77b730e59fcad89388999c640c6af081\":\"Former Time\",\"6fd7eb71d0d068e0fa8442406db61d67\":\"Cancel Appointment\",\"1806e2a1571c73208d346f3743226edc\":\"Cancel Selection\",\"ac29e0de1190bff1978da882e254f7b7\":\"No slots available\",\"e160affdeba842be7967968f137bb6f5\":\"{time} on {date} has been selected is unavailable. Please select another slot.\",\"01cc989baf2813a94fcfcdc2d9d76880\":\"There are {count} errors on this page. Please correct them before moving on.\",\"c454523809adffffac01e68888c06e79\":\"There is {count} error on this page. Please correct it before moving on.\",\"e7bd4eef1c98b459dc0ca34e5f354bca\":\"Well done! All errors are fixed.\",\"11c9b8d5c5f6e66a098966bb8f9f6dd6\":\"Enter a valid time\",\"f92965e2c8a7afb3c1b9a5c09a263636\":\"Done\",\"df2825f7ef9d4c1be7c63f7b1648b05f\":\"See Errors\",\"518140b6852b2fa6d4dbd732a9f7bc51\":\"Not enough stock for the current selection\",\"3430139a0dcc9ca2f6830a4a9e11f513\":\"Not enough stock for the current selection ({count} items left)\",\"826eadae3870bf9e64c7a7ff9b1cb181\":\"Sold Out\",\"8a9323944b4ed5128db7d1f0b2300c45\":\"Just Sold Out\",\"67d9458bf8d4c5216651b66b64d30e58\":\"Selection Sold Out\",\"a295510e038d1d9ee93f3a3f10795f68\":\"({count} items left)\",\"cd15c75505629a54911aa6c5eaca5778\":\"field has an error.\",\"902b0d55fddef6f8d651fe1035b7d4bd\":\"Error\",\"8c09001c99ecb6fdd8d6023fcf039054\":\"Signature\",\"dc30bc0c7914db5918da4263fce93ad2\":\"Clear\"},\"ru\":{\"03727ac48595a24daed975559c944a44\":\"\u0414\u0435\u043d\u044c\",\"7cbb885aa1164b390a0bc050a64e1812\":\"\u041c\u0435\u0441\u044f\u0446\",\"537c66b24ef5c83b7382cdc3f34885f2\":\"\u0413\u043e\u0434\",\"77587239bf4c54ea493c7033e1dbf636\":\"\u0424\u0430\u043c\u0438\u043b\u0438\u044f\",\"b55e509c697e4cca0e1d160a7806698f\":\"\u0427\u0430\u0441\",\"f670ea66cfb0e90bd6090472ad692694\":\"\u041c\u0438\u043d\u0443\u0442\u044b\",\"44749712dbec183e983dcd78a7736c41\":\"\u0414\u0430\u0442\u0430\",\"86f5978d9b80124f509bdb71786e929e\":\"\u042f\u043d\u0432\u0430\u0440\u044c\",\"659e59f062c75f81259d22786d6c44aa\":\"\u0424\u0435\u0432\u0440\u0430\u043b\u044c\",\"fa3e5edac607a88d8fd7ecb9d6d67424\":\"\u041c\u0430\u0440\u0442\",\"3fcf026bbfffb63fb24b8de9d0446949\":\"\u0410\u043f\u0440\u0435\u043b\u044c\",\"195fbb57ffe7449796d23466085ce6d8\":\"\u041c\u0430\u0439\",\"688937ccaf2a2b0c45a1c9bbba09698d\":\"\u0418\u044e\u043d\u044c\",\"1b539f6f34e8503c97f6d3421346b63c\":\"\u0418\u044e\u043b\u044c\",\"41ba70891fb6f39327d8ccb9b1dafb84\":\"\u0410\u0432\u0433\u0443\u0441\u0442\",\"cc5d90569e1c8313c2b1c2aab1401174\":\"\u0421\u0435\u043d\u0442\u044f\u0431\u0440\u044c\",\"eca60ae8611369fe28a02e2ab8c5d12e\":\"\u041e\u043a\u0442\u044f\u0431\u0440\u044c\",\"7e823b37564da492ca1629b4732289a8\":\"\u041d\u043e\u044f\u0431\u0440\u044c\",\"82331503174acbae012b2004f6431fa5\":\"\u0414\u0435\u043a\u0430\u0431\u0440\u044c\",\"9d1a0949c39e66a0cd65240bc0ac9177\":\"\u0412\u043e\u0441\u043a\u0440\u0435\u0441\u0435\u043d\u044c\u0435\",\"6f8522e0610541f1ef215a22ffa66ff6\":\"\u041f\u043e\u043d\u0435\u0434\u0435\u043b\u044c\u043d\u0438\u043a\",\"5792315f09a5d54fb7e3d066672b507f\":\"\u0412\u0442\u043e\u0440\u043d\u0438\u043a\",\"796c163589f295373e171842f37265d5\":\"\u0421\u0440\u0435\u0434\u0430\",\"78ae6f0cd191d25147e252dc54768238\":\"\u0427\u0435\u0442\u0432\u0435\u0440\u0433\",\"c33b138a163847cdb6caeeb7c9a126b4\":\"\u041f\u044f\u0442\u043d\u0438\u0446\u0430\",\"8b7051187b9191cdcdae6ed5a10e5adc\":\"\u0421\u0443\u0431\u0431\u043e\u0442\u0430\",\"1dd1c5fb7f25cd41b291d43a89e3aefd\":\"\u0421\u0435\u0433\u043e\u0434\u043d\u044f\",\"262f85cc9967ff615cfa8de8e2d125f8\":\"\u041c\u041c-\u0414\u0414-\u0413\u0413\u0413\u0413\",\"aaff974958972c1d45d45cb3b77bff79\":\"\u0423\u043b\u0438\u0446\u0430\",\"2b848a8cc886d253d21a77c43cd50aae\":\"\u0421\u041e\u0421\u0422\u041e\u042f\u041d\u0418\u0415\",\"6b19fc3d5e07bf4051873e59b536ce85\":\"\u0412\u044b\u0431\u0435\u0440\u0438\u0442\u0435 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padding-left: 30px;\n}\n.form-single-column .form-checkbox-item,\n.form-single-column .form-radio-item {\n  width: 100%;\n}\n.form-checkbox-item .editor-container div,\n.form-radio-item .editor-container div {\n  position: relative;\n}\n.form-checkbox-item .editor-container div:before,\n.form-radio-item .editor-container div:before {\n  display: inline-block;\n  vertical-align: middle;\n  left: 0;\n  width: 20px;\n  height: 20px;\n}\n.form-checkbox-item input,\n.form-radio-item input {\n  margin-top: 2px;\n}\n.form-checkbox:checked + label:before,\n.form-checkbox:checked + span:before {\n  background-color: #2e69ff;\n  border-color: #2e69ff;\n}\n.form-radio:checked + label:before,\n.form-radio:checked + span:before {\n  border-color: #2e69ff;\n}\n.form-radio:checked + label:after,\n.form-radio:checked + span:after {\n  background-color: #2e69ff;\n}\n.form-checkbox:hover + label:before,\n.form-checkbox:hover + span:before,\n.form-radio:hover + label:before,\n.form-radio:hover + span:before {\n  border-color: rgba(46, 105, 255, 0.5);\n  box-shadow: 0 0 0 2px rgba(46, 105, 255, 0.25);\n}\n.form-checkbox:focus + label:before,\n.form-checkbox:focus + span:before,\n.form-radio:focus + label:before,\n.form-radio:focus + span:before {\n  border-color: #2e69ff;\n  box-shadow: 0 0 0 3px rgba(46, 105, 255, 0.25);\n}\n.submit-button {\n  font-size: 12px;\n  font-weight: normal;\n  font-family: inherit;\n}\n.submit-button {\n  min-width: 180px;\n}\n.form-all .form-pagebreak-back,\n.form-all .form-pagebreak-next {\n  font-family: \"Inter\", sans-serif;\n  font-size: 12px;\n  font-weight: normal;\n}\n.form-all .form-pagebreak-back,\n.form-all .form-pagebreak-next {\n  min-width: 128px;\n}\nli[data-type=\"control_image\"] div {\n  text-align: left;\n}\nli[data-type=\"control_image\"] img {\n  border: none;\n  border-width: 0px !important;\n  border-style: solid !important;\n  border-color: false !important;\n}\n.supernova {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n  background-attachment: fixed;\n  background-size: auto;\n  background-size: cover;\n}\n.supernova {\n  background-image: none;\n}\n#stage {\n  background-image: none;\n}\n\/* | *\/\n.form-all {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n  background-size: cover;\n}\n.form-header-group {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n}\n.header-large h1.form-header {\n  font-size: 2em;\n}\n.header-large h2.form-header {\n  font-size: 1.5em;\n}\n.header-large h3.form-header {\n  font-size: 1.17em;\n}\n.header-large h1 + .form-subHeader {\n  font-size: 1em;\n}\n.header-large h2 + .form-subHeader {\n  font-size: .875em;\n}\n.header-large h3 + .form-subHeader {\n  font-size: .75em;\n}\n.header-default h1.form-header {\n  font-size: 2em;\n}\n.header-default h2.form-header {\n  font-size: 1.5em;\n}\n.header-default h3.form-header {\n  font-size: 1.17em;\n}\n.header-default h1 + .form-subHeader {\n  font-size: 1em;\n}\n.header-default h2 + .form-subHeader {\n  font-size: .875em;\n}\n.header-default h3 + .form-subHeader {\n  font-size: .75em;\n}\n.header-small h1.form-header {\n  font-size: 2em;\n}\n.header-small h2.form-header {\n  font-size: 1.5em;\n}\n.header-small h3.form-header {\n  font-size: 1.17em;\n}\n.header-small h1 + .form-subHeader {\n  font-size: 1em;\n}\n.header-small h2 + .form-subHeader {\n  font-size: .875em;\n}\n.header-small h3 + .form-subHeader {\n  font-size: .75em;\n}\n.form-header-group {\n  text-align: left;\n}\ndiv.form-header-group.header-large,\ndiv.form-header-group.hasImage {\n  margin: 0px -38px;\n}\ndiv.form-header-group.header-large,\ndiv.form-header-group.hasImage {\n  padding: 40px 52px;\n}\n.form-header-group .form-header,\n.form-header-group .form-subHeader {\n  color: -1;\n}\n.form-line-error {\n  -webkit-transition-property: none;\n  -moz-transition-property: none;\n  -ms-transition-property: none;\n  -o-transition-property: none;\n  transition-property: none;\n  -webkit-transition-duration: 0.3s;\n  -moz-transition-duration: 0.3s;\n  -ms-transition-duration: 0.3s;\n  -o-transition-duration: 0.3s;\n  transition-duration: 0.3s;\n  -webkit-transition-timing-function: ease;\n  -moz-transition-timing-function: ease;\n  -ms-transition-timing-function: ease;\n  -o-transition-timing-function: ease;\n  transition-timing-function: ease;\n  background-color: #fff4f4;\n}\n.form-line-error .form-error-message {\n  background-color: #f23a3c;\n  clear: both;\n  float: none;\n}\n.form-line-error .form-error-message .form-error-arrow {\n  border-bottom-color: #f23a3c;\n}\n.form-line-error input:not(#coupon-input),\n.form-line-error textarea,\n.form-line-error .form-validation-error {\n  border: 1px solid #f23a3c;\n  box-shadow: 0 0 3px #f23a3c;\n}\n.form-line-error {\n  -webkit-transition-property: none;\n  -moz-transition-property: none;\n  -ms-transition-property: none;\n  -o-transition-property: none;\n  transition-property: none;\n  -webkit-transition-duration: 0.3s;\n  -moz-transition-duration: 0.3s;\n  -ms-transition-duration: 0.3s;\n  -o-transition-duration: 0.3s;\n  transition-duration: 0.3s;\n  -webkit-transition-timing-function: ease;\n  -moz-transition-timing-function: ease;\n  -ms-transition-timing-function: ease;\n  -o-transition-timing-function: ease;\n  transition-timing-function: ease;\n  background-color: #fff4f4;\n}\n.form-line-active {\n  background-color: #f1f5ff;\n}\n\/* 29 - FORM COLUMNS *\/\n.form-line-column {\n  width: calc(100\/3 * 1% - 8px);\n}\n\n\/*__INSPECT_SEPERATOR__*\/\n.form-label.form-label-auto {\n    display : block;\n    float : none;\n    text-align : left;\n    width : 100%;\n}\n\n\/* Hide product price *\/\nspan.form-product-details {\n  display: none !important;\n}\n\/* end *\/\n    \/* Injected CSS Code *\/\n<\/style>\n\n<form class=\"jotform-form\" onsubmit=\"return typeof testSubmitFunction !== 'undefined' && testSubmitFunction();\" action=\"https:\/\/hipaa-submit.jotform.com\/submit\/261655706627161\" method=\"post\" enctype=\"multipart\/form-data\" name=\"form_261655706627161\" id=\"261655706627161\" accept-charset=\"utf-8\" autocomplete=\"on\"><input type=\"hidden\" name=\"formID\" value=\"261655706627161\" \/><input type=\"hidden\" id=\"JWTContainer\" value=\"\" \/><input type=\"hidden\" id=\"cardinalOrderNumber\" value=\"\" \/><input type=\"hidden\" id=\"jsExecutionTracker\" name=\"jsExecutionTracker\" value=\"build-date-1781818107763\" \/><input type=\"hidden\" id=\"submitSource\" name=\"submitSource\" value=\"unknown\" \/><input type=\"hidden\" id=\"submitDate\" name=\"submitDate\" value=\"undefined\" \/><input type=\"hidden\" id=\"buildDate\" name=\"buildDate\" value=\"1781818107763\" \/><input type=\"hidden\" name=\"uploadServerUrl\" value=\"https:\/\/upload.jotform.com\/upload\" \/><input type=\"hidden\" name=\"eventObserver\" value=\"1\" \/><input type=\"hidden\" name=\"eventObserverPayment\" value=\"control_payment\" \/>\n  <div id=\"formCoverLogo\" style=\"margin-bottom:32px\" class=\"form-cover-wrapper form-has-cover form-page-cover-image-align-center\">\n    <div class=\"form-page-cover-image-wrapper\" style=\"max-width:1080px\"><img fetchpriority=\"high\" decoding=\"async\" src=\"https:\/\/www.jotform.com\/uploads\/Hershel_hershel\/form_files\/Logo%20-%20DME%20PLUS%20OP%20Vector%20file.68d574a668d6c3.33595547.png\" class=\"form-page-cover-image\" width=\"380\" height=\"139\" alt=\"NEW FORM _ CUSTOM\" style=\"aspect-ratio:2.7338129496402876\" \/><\/div>\n  <\/div>\n  <div role=\"main\" class=\"form-all\">\n    <link type=\"text\/css\" rel=\"stylesheet\" media=\"all\" href=\"https:\/\/cdn.jotfor.ms\/s\/static\/a0da8db76e2\/css\/language-dropdown.css?4.1.68953\" \/>\n    <div class=\"cont\"><input type=\"text\" id=\"input_language\" name=\"input_language\" style=\"display:none\" \/>\n      <div class=\"language-dd\" id=\"langDd\" style=\"display:none\" aria-haspopup=\"listbox\" aria-controls=\"langList\" aria-expanded=\"false\">\n        <div class=\"dd-placeholder lang-emp\">Language<\/div>\n        <ul class=\"lang-list dn\" id=\"langList\" role=\"listbox\">\n          <li data-lang=\"en\" class=\"en\" role=\"option\" aria-selected=\"false\">English (US)<\/li>\n          <li data-lang=\"ru\" class=\"ru\" role=\"option\" aria-selected=\"false\">Russian<\/li>\n          <li data-lang=\"he\" class=\"he\" role=\"option\" aria-selected=\"false\">Hebrew<\/li>\n        <\/ul>\n      <\/div>\n    <\/div>\n    <ul class=\"form-section page-section\" role=\"presentation\">\n      <li class=\"form-line form-line-column form-col-1 jf-required\" data-type=\"control_datetime\" id=\"id_3\"><span class=\"form-label form-label-top\" id=\"label_3\"> Date of Evaluation<span class=\"form-required\" aria-hidden=\"true\">*<\/span> <\/span>\n        <div id=\"cid_3\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <div data-wrapper-react=\"true\" role=\"group\" aria-labelledby=\"label_3\">\n            <div style=\"display:none\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input class=\"form-textbox validate[required, limitDate]\" id=\"month_3\" name=\"q3_date[month]\" type=\"tel\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_3 sublabel_3_month\" value=\"\" \/><span class=\"date-separate\" aria-hidden=\"true\">\u00a0-<\/span><label class=\"form-sub-label\" for=\"month_3\" id=\"sublabel_3_month\" style=\"min-height:13px\">Month<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input class=\"form-textbox validate[required, limitDate]\" id=\"day_3\" name=\"q3_date[day]\" type=\"tel\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_3 sublabel_3_day\" value=\"\" \/><span class=\"date-separate\" aria-hidden=\"true\">\u00a0-<\/span><label class=\"form-sub-label\" for=\"day_3\" id=\"sublabel_3_day\" style=\"min-height:13px\">Day<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input class=\"form-textbox validate[required, limitDate]\" id=\"year_3\" name=\"q3_date[year]\" type=\"tel\" size=\"4\" data-maxlength=\"4\" data-age=\"\" maxLength=\"4\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_3 sublabel_3_year\" value=\"\" \/><label class=\"form-sub-label\" for=\"year_3\" id=\"sublabel_3_year\" style=\"min-height:13px\">Year<\/label><\/span><\/div><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input class=\"form-textbox validate[required, limitDate, validateLiteDate]\" id=\"lite_mode_3\" type=\"text\" size=\"12\" data-maxlength=\"12\" maxLength=\"12\" data-age=\"\" aria-labelledby=\"label_3 sublabel_3_litemode\" required=\"\" data-format=\"mmddyyyy\" data-seperator=\"-\" placeholder=\"MM-DD-YYYY\" data-placeholder=\"MM-DD-YYYY\" autoComplete=\"off\" value=\"\" \/><button type=\"button\" class=\"showAutoCalendar newDefaultTheme-dateIcon focusable icon-liteMode\" id=\"input_3_pick\" data-component=\"datetime\" aria-label=\"Choose date\" aria-controls=\"calendar_3\" aria-haspopup=\"dialog\" aria-expanded=\"false\" data-allow-time=\"No\" data-version=\"v2\"><\/button><label class=\"form-sub-label\" for=\"lite_mode_3\" id=\"sublabel_3_litemode\" style=\"min-height:13px\">Date<\/label><\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_5\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_5\" class=\"form-header\" data-component=\"header\">Patient Information<\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line fixed-width form-line-column form-col-2 jf-required\" data-type=\"control_textbox\" id=\"id_6\"><label class=\"form-label form-label-top\" id=\"label_6\" for=\"input_6\"> FACILITY NAME\u00a0<span class=\"form-required\" aria-hidden=\"true\">*<\/span> <\/label>\n        <div id=\"cid_6\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_6\" name=\"q6_facilityName\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:372px\" size=\"372\" data-component=\"textbox\" aria-labelledby=\"label_6 sublabel_input_6\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_6\" id=\"sublabel_input_6\" style=\"min-height:13px\">What facility is the patient in?<\/label><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line fixed-width form-line-column form-col-3 jf-required\" data-type=\"control_textbox\" id=\"id_8\"><label class=\"form-label form-label-top\" id=\"label_8\" for=\"input_8\"> FACILITY ADDRESS<span class=\"form-required\" aria-hidden=\"true\">*<\/span> <\/label>\n        <div id=\"cid_8\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_8\" name=\"q8_facilityName8\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:372px\" size=\"372\" data-component=\"textbox\" aria-labelledby=\"label_8 sublabel_input_8\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_8\" id=\"sublabel_input_8\" style=\"min-height:13px\">Street Address<\/label><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line fixed-width form-line-column form-col-4\" data-type=\"control_textbox\" id=\"id_9\"><label class=\"form-label form-label-top\" id=\"label_9\" for=\"input_9\"> CITY <\/label>\n        <div id=\"cid_9\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_9\" name=\"q9_city\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:214px\" size=\"214\" data-component=\"textbox\" aria-labelledby=\"label_9\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line fixed-width form-line-column form-col-5\" data-type=\"control_textbox\" id=\"id_7\"><label class=\"form-label form-label-top\" id=\"label_7\" for=\"input_7\"> STATE <\/label>\n        <div id=\"cid_7\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_7\" name=\"q7_facilityAddress\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:325px\" size=\"325\" data-component=\"textbox\" aria-labelledby=\"label_7\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line fixed-width form-line-column form-col-6\" data-type=\"control_textbox\" id=\"id_10\"><label class=\"form-label form-label-top\" id=\"label_10\" for=\"input_10\"> ZIP CODE <\/label>\n        <div id=\"cid_10\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_10\" name=\"q10_state\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:321px\" size=\"321\" data-component=\"textbox\" aria-labelledby=\"label_10\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-7 jf-required\" data-type=\"control_textbox\" id=\"id_11\"><label class=\"form-label form-label-top\" id=\"label_11\" for=\"input_11\"> REQUESTER (DOR\/PT\/OT\/OTHER) NAME<span class=\"form-required\" aria-hidden=\"true\">*<\/span> <\/label>\n        <div id=\"cid_11\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <input type=\"text\" id=\"input_11\" name=\"q11_typeA\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_11\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-8 jf-required\" data-type=\"control_textbox\" id=\"id_12\"><label class=\"form-label form-label-top\" id=\"label_12\" for=\"input_12\"> REQUESTER EMAIL ADDRESS <span class=\"form-required\" aria-hidden=\"true\">*<\/span> <\/label>\n        <div id=\"cid_12\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_12\" name=\"q12_requesterdorptotother\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_12 sublabel_input_12\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_12\" id=\"sublabel_input_12\" style=\"min-height:13px\">HIPPA compliant verified email addresses\u00a0only.<\/label><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-9 jf-required\" data-type=\"control_textbox\" id=\"id_15\"><label class=\"form-label form-label-top\" id=\"label_15\" for=\"input_15\"> PATIENT NAME<span class=\"form-required\" aria-hidden=\"true\">*<\/span> <\/label>\n        <div id=\"cid_15\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <input type=\"text\" id=\"input_15\" name=\"q15_requesterdorptotother15\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_15\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-10 jf-required\" data-type=\"control_textbox\" id=\"id_16\"><label class=\"form-label form-label-top\" id=\"label_16\" for=\"input_16\"> PATIENT DOB<span class=\"form-required\" aria-hidden=\"true\">*<\/span> <\/label>\n        <div id=\"cid_16\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <input type=\"text\" id=\"input_16\" name=\"q16_patientName\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_16\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-11 jf-required\" data-type=\"control_fileupload\" id=\"id_13\"><label class=\"form-label form-label-top\" id=\"label_13\" for=\"input_13\"> UPLOAD FACESHEET <span class=\"form-required\" aria-hidden=\"true\">*<\/span> <\/label>\n        <div id=\"cid_13\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div class=\"jfQuestion-fields\" data-wrapper-react=\"true\">\n            <div class=\"jfField isFilled\">\n              <div class=\"jfUpload-wrapper\">\n                <div class=\"jfUpload-container\">\n                  <div class=\"jfUpload-button-container\">\n                    <div class=\"jfUpload-button\" aria-hidden=\"true\" tabindex=\"0\" style=\"display:none\" data-version=\"v2\">Browse Files<div class=\"jfUpload-heading forDesktop\">Drag and drop files here<\/div>\n                      <div class=\"jfUpload-heading forMobile\">Choose a file<\/div>\n                    <\/div>\n                  <\/div>\n                <\/div>\n                <div class=\"jfUpload-files-container\">\n                  <div class=\"validate[multipleUpload]\"><input type=\"file\" id=\"input_13\" name=\"q13_fileUpload[]\" multiple=\"\" class=\"form-upload-multiple validate[required]\" data-imagevalidate=\"yes\" data-file-accept=\"pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif\" data-limit-file-size=\"Yes\" data-file-maxsize=\"10854\" data-file-minsize=\"0\" data-file-limit=\"\" data-component=\"fileupload\" required=\"\" aria-label=\"Browse Files\" \/><\/div>\n                <\/div>\n              <\/div>\n              <div data-wrapper-react=\"true\"><\/div>\n            <\/div><span style=\"display:none\" class=\"cancelText\">Cancel<\/span><span style=\"display:none\" class=\"ofText\">of<\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-12 jf-required\" data-type=\"control_fileupload\" id=\"id_14\"><label class=\"form-label form-label-top\" id=\"label_14\" for=\"input_14\"> UPLOAD THERAPY NOTES<span class=\"form-required\" aria-hidden=\"true\">*<\/span> <\/label>\n        <div id=\"cid_14\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div class=\"jfQuestion-fields\" data-wrapper-react=\"true\">\n            <div class=\"jfField isFilled\">\n              <div class=\"jfUpload-wrapper\">\n                <div class=\"jfUpload-container\">\n                  <div class=\"jfUpload-button-container\">\n                    <div class=\"jfUpload-button\" aria-hidden=\"true\" tabindex=\"0\" style=\"display:none\" data-version=\"v2\">Browse Files<div class=\"jfUpload-heading forDesktop\">Drag and drop files here<\/div>\n                      <div class=\"jfUpload-heading forMobile\">Choose a file<\/div>\n                    <\/div>\n                  <\/div>\n                <\/div>\n                <div class=\"jfUpload-files-container\">\n                  <div class=\"validate[multipleUpload]\"><input type=\"file\" id=\"input_14\" name=\"q14_uploadFacesheet[]\" multiple=\"\" class=\"form-upload-multiple validate[required]\" data-imagevalidate=\"yes\" data-file-accept=\"pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif\" data-limit-file-size=\"Yes\" data-file-maxsize=\"10854\" data-file-minsize=\"0\" data-file-limit=\"\" data-component=\"fileupload\" required=\"\" aria-label=\"Browse Files\" \/><\/div>\n                <\/div>\n              <\/div>\n              <div data-wrapper-react=\"true\"><\/div>\n            <\/div><span style=\"display:none\" class=\"cancelText\">Cancel<\/span><span style=\"display:none\" class=\"ofText\">of<\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 form-line-column-clear\" data-type=\"control_datetime\" id=\"id_18\"><span class=\"form-label form-label-top\" id=\"label_18\"> DATE OF MED A DC <\/span>\n        <div id=\"cid_18\" class=\"form-input-wide\" data-layout=\"half\">\n          <div data-wrapper-react=\"true\" role=\"group\" aria-labelledby=\"label_18\">\n            <div style=\"display:none\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input class=\"form-textbox validate[limitDate]\" id=\"month_18\" name=\"q18_date18[month]\" type=\"tel\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" autoComplete=\"off\" aria-labelledby=\"label_18 sublabel_18_month\" value=\"\" \/><span class=\"date-separate\" aria-hidden=\"true\">\u00a0-<\/span><label class=\"form-sub-label\" for=\"month_18\" id=\"sublabel_18_month\" style=\"min-height:13px\">Month<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input class=\"form-textbox validate[limitDate]\" id=\"day_18\" name=\"q18_date18[day]\" type=\"tel\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" autoComplete=\"off\" aria-labelledby=\"label_18 sublabel_18_day\" value=\"\" \/><span class=\"date-separate\" aria-hidden=\"true\">\u00a0-<\/span><label class=\"form-sub-label\" for=\"day_18\" id=\"sublabel_18_day\" style=\"min-height:13px\">Day<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input class=\"form-textbox validate[limitDate]\" id=\"year_18\" name=\"q18_date18[year]\" type=\"tel\" size=\"4\" data-maxlength=\"4\" data-age=\"\" maxLength=\"4\" autoComplete=\"off\" aria-labelledby=\"label_18 sublabel_18_year\" value=\"\" \/><label class=\"form-sub-label\" for=\"year_18\" id=\"sublabel_18_year\" style=\"min-height:13px\">Year<\/label><\/span><\/div><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input class=\"form-textbox validate[limitDate, validateLiteDate]\" id=\"lite_mode_18\" type=\"text\" size=\"12\" data-maxlength=\"12\" maxLength=\"12\" data-age=\"\" aria-labelledby=\"label_18 sublabel_18_litemode\" data-format=\"mmddyyyy\" data-seperator=\"-\" placeholder=\"MM-DD-YYYY\" data-placeholder=\"MM-DD-YYYY\" autoComplete=\"off\" value=\"\" \/><button type=\"button\" class=\"showAutoCalendar newDefaultTheme-dateIcon focusable icon-liteMode\" id=\"input_18_pick\" data-component=\"datetime\" aria-label=\"Choose date\" aria-controls=\"calendar_18\" aria-haspopup=\"dialog\" aria-expanded=\"false\" data-allow-time=\"No\" data-version=\"v2\"><\/button><label class=\"form-sub-label\" for=\"lite_mode_18\" id=\"sublabel_18_litemode\" style=\"min-height:13px\">Date<\/label><\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2\" data-type=\"control_datetime\" id=\"id_19\"><span class=\"form-label form-label-top\" id=\"label_19\"> DATE OF DC TO HOME <\/span>\n        <div id=\"cid_19\" class=\"form-input-wide\" data-layout=\"half\">\n          <div data-wrapper-react=\"true\" role=\"group\" aria-labelledby=\"label_19\">\n            <div style=\"display:none\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input class=\"form-textbox validate[limitDate]\" id=\"month_19\" name=\"q19_dateOf[month]\" type=\"tel\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" autoComplete=\"off\" aria-labelledby=\"label_19 sublabel_19_month\" value=\"\" \/><span class=\"date-separate\" aria-hidden=\"true\">\u00a0-<\/span><label class=\"form-sub-label\" for=\"month_19\" id=\"sublabel_19_month\" style=\"min-height:13px\">Month<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input class=\"form-textbox validate[limitDate]\" id=\"day_19\" name=\"q19_dateOf[day]\" type=\"tel\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" autoComplete=\"off\" aria-labelledby=\"label_19 sublabel_19_day\" value=\"\" \/><span class=\"date-separate\" aria-hidden=\"true\">\u00a0-<\/span><label class=\"form-sub-label\" for=\"day_19\" id=\"sublabel_19_day\" style=\"min-height:13px\">Day<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input class=\"form-textbox validate[limitDate]\" id=\"year_19\" name=\"q19_dateOf[year]\" type=\"tel\" size=\"4\" data-maxlength=\"4\" data-age=\"\" maxLength=\"4\" autoComplete=\"off\" aria-labelledby=\"label_19 sublabel_19_year\" value=\"\" \/><label class=\"form-sub-label\" for=\"year_19\" id=\"sublabel_19_year\" style=\"min-height:13px\">Year<\/label><\/span><\/div><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input class=\"form-textbox validate[limitDate, validateLiteDate]\" id=\"lite_mode_19\" type=\"text\" size=\"12\" data-maxlength=\"12\" maxLength=\"12\" data-age=\"\" aria-labelledby=\"label_19 sublabel_19_litemode\" data-format=\"mmddyyyy\" data-seperator=\"-\" placeholder=\"MM-DD-YYYY\" data-placeholder=\"MM-DD-YYYY\" autoComplete=\"off\" value=\"\" \/><button type=\"button\" class=\"showAutoCalendar newDefaultTheme-dateIcon focusable icon-liteMode\" id=\"input_19_pick\" data-component=\"datetime\" aria-label=\"Choose date\" aria-controls=\"calendar_19\" aria-haspopup=\"dialog\" aria-expanded=\"false\" data-allow-time=\"No\" data-version=\"v2\"><\/button><label class=\"form-sub-label\" for=\"lite_mode_19\" id=\"sublabel_19_litemode\" style=\"min-height:13px\">Date<\/label><\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line fixed-width form-line-column form-col-3\" data-type=\"control_textbox\" id=\"id_57\"><label class=\"form-label form-label-top\" id=\"label_57\" for=\"input_57\"> TREATING PROVIDER NAME (DO\/MD\/NP) <\/label>\n        <div id=\"cid_57\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_57\" name=\"q57_treatingProvider\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:450px\" size=\"450\" data-component=\"textbox\" aria-labelledby=\"label_57\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line fixed-width form-line-column form-col-4\" data-type=\"control_textbox\" id=\"id_30\"><label class=\"form-label form-label-top\" id=\"label_30\" for=\"input_30\"> Treating Provider NPI <\/label>\n        <div id=\"cid_30\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_30\" name=\"q30_typeA30\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:450px\" size=\"450\" data-component=\"textbox\" aria-labelledby=\"label_30\" value=\"\" \/> <\/div>\n      <\/li>\n      <li id=\"cid_20\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_20\" class=\"form-header\" data-component=\"header\">Item Information<\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line card-1col jf-required\" data-type=\"control_payment\" id=\"id_48\" data-payment=\"true\">\n        <h4 style=\"margin-top: 0;\" class=\"form-label form-label-top category-enabled p-filter-one-column\" id=\"label_48\" for=\"input_48\"> Expand to View Products \u2013 Click Any Image for Sizing Info<span class=\"form-required\" aria-hidden=\"true\">*<\/span> <\/h4>\n        <div id=\"cid_48\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div data-wrapper-react=\"true\">\n            <div data-wrapper-react=\"true\" class=\"product-container-wrapper\">\n              <div class=\"filter-container\">\n                <div class=\"multi-select-dropdown category-title-enabled hasSelectAll\" id=\"payment-category-dropdown\">\n                  <div class=\"dropdown-container\">\n                    <div class=\"select-area\" tabindex=\"0\" role=\"button\" aria-expanded=\"false\"><span class=\"dropdown-hint\">Categories:<\/span><span class=\"selected-values\">All<\/span><i class=\"icon\"><\/i><\/div>\n                    <div class=\"select-content\">\n                      <div class=\"options\">\n                        <div aria-label=\"Categories:\" class=\"option selected\"><input type=\"checkbox\" readonly=\"\" checked=\"\" value=\"All\" \/><span>All<\/span><\/div>\n                      <\/div>\n                    <\/div>\n                  <\/div>\n                <\/div>\n              <\/div><input type=\"hidden\" name=\"simple_fpc\" data-payment_type=\"payment\" data-component=\"payment1\" value=\"48\" \/><input type=\"hidden\" name=\"payment_transaction_uuid\" id=\"paymentTransactionId\" \/><input type=\"hidden\" name=\"payment_version\" id=\"payment_version\" value=\"4\" \/><input type=\"hidden\" name=\"payment_total_checksum\" id=\"payment_total_checksum\" data-component=\"payment2\" \/><input type=\"hidden\" name=\"payment_discount_value\" id=\"payment_discount_value\" data-component=\"payment3\" \/>\n              <div id=\"image-overlay\" class=\"overlay-content\" style=\"display:none\"><img id=\"current-image\" \/><span class=\"lb-prev-button\">prev<\/span><span class=\"lb-next-button\">next<\/span><span class=\"lb-close-button\">( X )<\/span><span class=\"image-overlay-product-container\">\n                  <ul class=\"form-overlay-item\" pid=\"1018\" hasicon=\"false\" hasimages=\"false\" iconvalue=\"\"><\/ul>\n                  <ul class=\"form-overlay-item\" pid=\"1017\" hasicon=\"false\" hasimages=\"false\" iconvalue=\"\"><\/ul>\n                <\/span><\/div>\n              <div data-wrapper-react=\"true\"><span tabindex=\"0\" class=\"form-product-item hover-product-item  show_desc show_option full_img new_ui\" categories=\"non-categorized\" pid=\"1018\" aria-labelledby=\"label_48\">\n                  <div data-wrapper-react=\"true\" class=\"form-product-item-detail new_ui\">\n                    <div class=\"p_col\">\n                      <div class=\"p_checkbox\"><input class=\"form-checkbox validate[required]  form-product-input\" type=\"checkbox\" id=\"input_48_1018\" name=\"q48_expandHere[][id]\" data-inputname=\"q48_expandHere[][id]\" readonly=\"\" aria-label=\"Select Product: Custom Orthotic:\" data-is-default-required=\"false\" data-is-default-selected=\"false\" value=\"1018\" \/>\n                        <div class=\"checked\"><\/div>\n                        <div class=\"select_border\"><\/div>\n                      <\/div>\n                    <\/div>\n                    <div class=\"p_image\">\n                      <div class=\"image_area \"><\/div>\n                    <\/div>\n                    <div for=\"input_48_1018\" class=\"form-product-container\"><span data-wrapper-react=\"true\">\n                        <div class=\"title_description\"><span class=\"form-product-name\" id=\"product-name-input_48_1018\">Custom Orthotic:<\/span><span class=\"form-product-description\" id=\"product-name-description-input_48_1018\"><span class=\"payment-jot-editor payment-jot-editor-view\" id=\"payment-jot-editor-input_48_1018\">\n                              <p style=\"margin:0\" jot-element-type=\"paragraph\"><span data-slate-zero-width=\"n\" data-slate-length=\"0\"><br \/><\/span><\/p>\n                            <\/span><\/span><\/div><span class=\"form-product-details\"><strong><span data-wrapper-react=\"true\"><span class=\"sr-only\">Free<\/span><span class=\"freeCurr\" style=\"display:none\" aria-hidden=\"true\">$<\/span><span id=\"input_48_1018_price\" aria-hidden=\"true\">\u00a0Free<\/span><span class=\"freeCurr\" style=\"display:none\" aria-hidden=\"true\"><\/span><\/span><\/strong><\/span>\n                      <\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><label class=\"form-sub-label\" for=\"input_48_custom_1018_0\" style=\"min-height:13px\">Side<\/label><span class=\"select_cont\"><select class=\"form-dropdown validate[required]\" name=\"q48_expandHere[special_1018][item_0]\" id=\"input_48_custom_1018_0\" aria-label=\"Select Side\">\n                            <option value=\"Left\">Left<\/option>\n                            <option value=\"Right\">Right<\/option>\n                            <option value=\"Bilateral (Both)\">Bilateral (Both)<\/option>\n                          <\/select><\/span><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><label class=\"form-sub-label\" for=\"input_48_custom_1018_1\" style=\"min-height:13px\">Type<\/label><span class=\"select_cont\"><select class=\"form-dropdown validate[required]\" name=\"q48_expandHere[special_1018][item_1]\" id=\"input_48_custom_1018_1\" aria-label=\"Select Type\">\n                            <option value=\"AK\">AK<\/option>\n                            <option value=\"BK\">BK<\/option>\n                          <\/select><\/span><\/span><\/div>\n                    <div class=\"focus_action_button_container\" style=\"pointer-events:auto\"><a class=\"btn-inline-product-delete\" tabindex=\"0\" role=\"button\" aria-label=\"Delete Product\">\u00a0<\/a><a class=\"btn-inline-product-settings\" tabindex=\"0\" role=\"button\" aria-label=\"Product Settings\">\u00a0<\/a><\/div>\n                  <\/div>\n                <\/span>\n                <div class=\"p_item_separator \"><\/div><span tabindex=\"0\" class=\"form-product-item hover-product-item  show_desc show_option new_ui\" categories=\"non-categorized\" pid=\"1017\" aria-labelledby=\"label_48\">\n                  <div data-wrapper-react=\"true\" class=\"form-product-item-detail new_ui\">\n                    <div class=\"p_col\">\n                      <div class=\"p_checkbox\"><input class=\"form-checkbox validate[required]  form-product-input\" type=\"checkbox\" id=\"input_48_1017\" name=\"q48_expandHere[][id]\" data-inputname=\"q48_expandHere[][id]\" readonly=\"\" aria-label=\"Select Product: Prosthetic\" data-is-default-required=\"false\" data-is-default-selected=\"false\" value=\"1017\" \/>\n                        <div class=\"checked\"><\/div>\n                        <div class=\"select_border\"><\/div>\n                      <\/div>\n                    <\/div>\n                    <div class=\"p_image\">\n                      <div class=\"image_area \"><\/div>\n                    <\/div>\n                    <div for=\"input_48_1017\" class=\"form-product-container\"><span data-wrapper-react=\"true\">\n                        <div class=\"title_description\"><span class=\"form-product-name\" id=\"product-name-input_48_1017\">Prosthetic<\/span><span class=\"form-product-description\" id=\"product-name-description-input_48_1017\"><span class=\"payment-jot-editor payment-jot-editor-view\" id=\"payment-jot-editor-input_48_1017\">\n                              <p style=\"margin:0\" jot-element-type=\"paragraph\"><span data-slate-zero-width=\"n\" data-slate-length=\"0\"><br \/><\/span><\/p>\n                            <\/span><\/span><\/div><span class=\"form-product-details\"><strong><span data-wrapper-react=\"true\"><span class=\"sr-only\">Free<\/span><span class=\"freeCurr\" style=\"display:none\" aria-hidden=\"true\">$<\/span><span id=\"input_48_1017_price\" aria-hidden=\"true\">\u00a0Free<\/span><span class=\"freeCurr\" style=\"display:none\" aria-hidden=\"true\"><\/span><\/span><\/strong><\/span>\n                      <\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><label class=\"form-sub-label\" for=\"input_48_custom_1017_0\" style=\"min-height:13px\">Side<\/label><span class=\"select_cont\"><select class=\"form-dropdown validate[required]\" name=\"q48_expandHere[special_1017][item_0]\" id=\"input_48_custom_1017_0\" aria-label=\"Select Side\">\n                            <option value=\"Left\">Left<\/option>\n                            <option value=\"Right\">Right<\/option>\n                            <option value=\"Bilateral (Both)\">Bilateral (Both)<\/option>\n                          <\/select><\/span><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><label class=\"form-sub-label\" for=\"input_48_custom_1017_1\" style=\"min-height:13px\">Type<\/label><span class=\"select_cont\"><select class=\"form-dropdown validate[required]\" name=\"q48_expandHere[special_1017][item_1]\" id=\"input_48_custom_1017_1\" aria-label=\"Select Type\">\n                            <option value=\"AK\">AK<\/option>\n                            <option value=\"BK\">BK<\/option>\n                          <\/select><\/span><\/span><\/div>\n                    <div class=\"focus_action_button_container\" style=\"pointer-events:auto\"><a class=\"btn-inline-product-delete\" tabindex=\"0\" role=\"button\" aria-label=\"Delete Product\">\u00a0<\/a><a class=\"btn-inline-product-settings\" tabindex=\"0\" role=\"button\" aria-label=\"Product Settings\">\u00a0<\/a><\/div>\n                  <\/div>\n                <\/span>\n                <div class=\"payment_footer new_ui \">\n                  <div class=\"total_area\"><\/div>\n                <\/div>\n              <\/div>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_78\">\n        <div id=\"cid_78\" class=\"form-input-wide\" data-layout=\"full\">\n          <div id=\"text_78\" class=\"form-html\" data-component=\"text\" tabindex=\"-1\">\n            <p>\u00a0<\/p>\n            <p><em>I further verify that I have received information containing: Customer Bill of Rights and Responsibilities, Medicare Supplier Standards, General and emergency contact information, Customer Satisfaction Survey, HIPAA Privacy Notice, Capped Rental Information (Medicare Rentals), Company Grievance Process, Home and equipment safety information, equipment cleaning instructions (if applicable), prevention of infection, warranty information, the scope of services provided and possible associated fees. I understand my option to purchase or rent applicable DME items.<\/em><\/p>\n            <p><em><a href=\"https:\/\/dmeplususa.com\/wp-content\/uploads\/2025\/05\/25-standards-full.pdf\" target=\"_blank\" rel=\"nofollow\">Download and Review the CMS supplier standards<\/a><\/em><\/p>\n            <p><em><a href=\"https:\/\/www.state.gov\/patient-bill-of-rights-and-responsibilities\/\" target=\"_blank\" rel=\"nofollow\">Download and Review\u00a0Patient-bill-of-rights-and-responsibilities<\/a><\/em><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_59\">\n        <div id=\"cid_59\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"divider\" data-component=\"divider\" style=\"border-bottom-width:1px;border-bottom-style:solid;border-color:#e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:15px\"><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_75\">\n        <div id=\"cid_75\" class=\"form-input-wide\" data-layout=\"full\">\n          <div id=\"text_75\" class=\"form-html\" data-component=\"text\" tabindex=\"-1\"><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line fixed-width jf-required\" data-type=\"control_signature\" id=\"id_79\" data-signature-draw=\"Yes\" data-signature-typed=\"No\" data-signature-color=\"No\" data-signature-font=\"No\" data-use-jotform-sign=\"No\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_79\" for=\"input_79\"> PATIENT SIGNATURE-DOR\/OT\/PT\/POA CAN SIGN ON PATIENTS BEHALF IF NEEDED. <span class=\"form-required\" aria-hidden=\"true\">*<\/span> <\/label>\n        <div id=\"cid_79\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <div data-wrapper-react=\"true\">\n            <div id=\"signature_pad_79\" class=\"form-advanced-signature-wrapper\" data-component=\"advanced-signature\" data-id=\"79\" data-required=\"Yes\" data-width=\"500\" data-height=\"114\" data-signature-draw=\"Yes\" data-signature-typed=\"No\" data-signature-color=\"No\" data-signature-font=\"No\" data-signature-default-method=\"\" data-use-jotform-sign=\"No\" style=\"border:none;background:transparent\"><input type=\"hidden\" name=\"q79_signature\" class=\"output4 validate[required]\" id=\"input_79\" value=\"\" \/><\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_button\" id=\"id_2\">\n        <div id=\"cid_2\" class=\"form-input-wide\" data-layout=\"full\">\n          <div data-align=\"auto\" class=\"form-buttons-wrapper form-buttons-auto   jsTest-button-wrapperField\"><button id=\"input_2\" type=\"submit\" class=\"form-submit-button submit-button jf-form-buttons jsTest-submitField legacy-submit\" data-component=\"button\" data-content=\"\">Continue<\/button><\/div>\n        <\/div>\n      <\/li>\n      <li style=\"clear:both\"><\/li>\n      <li style=\"display:none\">Should be Empty: <input type=\"text\" name=\"website\" value=\"\" type=\"hidden\" \/><\/li>\n    <\/ul>\n  <\/div>\n  <script>\n    JotForm.showJotFormPowered = \"0\";\n  <\/script>\n  <script>\n    JotForm.poweredByText = \"Powered by Jotform\";\n  <\/script>\n  <script>\n    JotForm.hipaa = true;\n  <\/script>\n  <script>\n    JotForm.showHIPAABadge = true;\n  <\/script><input type=\"hidden\" class=\"simple_spc\" id=\"simple_spc\" name=\"simple_spc\" value=\"261655706627161\" \/>\n  <script type=\"text\/javascript\">\n    var all_spc = document.querySelectorAll(\"form[id='261655706627161'] .si\" + \"mple\" + \"_spc\");\n    for (var i = 0; i < all_spc.length; i++)\n    {\n      all_spc[i].value = \"261655706627161-261655706627161\";\n    }\n  <\/script>\n<\/form>\n<div id=\"sr-status-message\" class=\"sr-only\" role=\"status\" aria-live=\"polite\" style=\"font-size: 0;\"><\/div><script type=\"text\/javascript\">JotForm.ownerView=true;<\/script><script type=\"text\/javascript\">JotForm.forwardToHIPAA=true;<\/script><script type=\"text\/javascript\">JotForm.isNewSACL=true;<\/script><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-f2653a0 elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"f2653a0\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-adced7a\" data-id=\"adced7a\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-ff14294 elementor-widget elementor-widget-heading\" data-id=\"ff14294\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">You simply\nreach out.<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-dd497cb elementor-widget elementor-widget-text-editor\" data-id=\"dd497cb\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tWe coordinate every step of the bracing process for your residents from insurance and<br>\nauthorization to delivery so your staff can focus on care, and your patients can focus on\u00a0recovery.\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-d80bf42 elementor-widget elementor-widget-text-editor\" data-id=\"d80bf42\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<h4><strong>We arrange\nyour care.<\/strong><\/h4>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6882bbc elementor-widget elementor-widget-text-editor\" data-id=\"6882bbc\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>THAT\u2019S DME+.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6813ccc elementor-widget elementor-widget-image\" data-id=\"6813ccc\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;motion_fx_motion_fx_scrolling&quot;:&quot;yes&quot;,&quot;motion_fx_devices&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/dmeplususa.com\/wp-content\/uploads\/elementor\/thumbs\/S-rgp0ovf6221ov2h5ejq2oi90jrkanojnw5dsggtq46.png\" title=\"+S\" alt=\"+S\" loading=\"lazy\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-d72926b elementor-widget elementor-widget-image\" data-id=\"d72926b\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;motion_fx_motion_fx_scrolling&quot;:&quot;yes&quot;,&quot;motion_fx_devices&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/dmeplususa.com\/wp-content\/uploads\/elementor\/thumbs\/S-rgp0ovf6221ov2h5ejq2oi90jrkanojnw5dsggtq46.png\" title=\"+S\" alt=\"+S\" loading=\"lazy\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-0ab740e elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"0ab740e\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-d1ac34c\" data-id=\"d1ac34c\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Custom orthotic\/Prosthetic Request Form For the states Of NY, NJ &amp; Eastern PA Language English (US) Russian Hebrew Date of Evaluation* \u00a0&#8211;Month\u00a0&#8211;DayYearDate Patient Information FACILITY NAME\u00a0* What facility is the patient in? FACILITY ADDRESS* Street Address CITY STATE ZIP CODE REQUESTER (DOR\/PT\/OT\/OTHER) NAME* REQUESTER EMAIL ADDRESS * HIPPA compliant verified email addresses\u00a0only. PATIENT NAME* PATIENT [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_joinchat":[],"footnotes":""},"class_list":["post-3628","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Request Custom Brace - DME Plus<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/dmeplususa.com\/pt\/request-custom-brace\/\" \/>\n<meta property=\"og:locale\" content=\"pt_PT\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Request Custom Brace - DME Plus\" \/>\n<meta property=\"og:description\" content=\"Custom orthotic\/Prosthetic Request Form For the states Of NY, NJ &amp; Eastern PA Language English (US) Russian Hebrew Date of Evaluation* \u00a0&#8211;Month\u00a0&#8211;DayYearDate Patient Information FACILITY NAME\u00a0* What facility is the patient in? 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