Membership Application

* = Required


Legal Company Name:*
DBA:

Mailing Address:*
City:*	State:*
Zip:*	County:
Gen Mgr Contact Name:*	Email:
Phone:*	Alt Phone: Fax:

Remit Address:
City:	State:
Zip:	County:
Billing/Acct Rec. Contact:	Email:
Phone:	Alt Phone: Fax:

Do you have a NPI #? Yes No
Do you have a Medicare #? Yes No
Do you have a Medicaid #? Yes No

Is your company accredited by ABC? * Yes No
In what disciplines are you accredited? Prosthetics Orthotics Other

Do you employ staff credentialed in the following categories? If so, How Many?
ABC Certified Prosthetist-Orthotist (CPO) #
ABC Certified Prosthetist (CP) #
ABC Certified Orthotist (CO) #
ABC Registered Technician (RTO, RTP, RTPO) #
ABC Registered Assistant (ROA, RPA, RPOA) #
ABC Registered Fitter (RFO, RFM, RFOM) #
BOC Prosthetist (BOCP) #
BOC Certified Orthotic Fitter (COF) #
BOC Certified Mastectomy Fitter (CMF) #
Are you required to have a state license to provide services? Yes No

Who is your liability carrier?