Amputation Navigator

Templates and checklists

Official forms are on the authorities' own sites. What you will find here are the lists that, in my experience, are worth having ready before you walk into an appointment, and the records that later turn out to be proof.

Paperwork around a prosthesis has one thing in common. Almost everything depends on a document issued by somebody else, but the content of that document depends on what you say and what you bring. The doctor records a mobility level based on a conversation. The medical justification comes from what you describe. The clerk assesses your application by what you attached to it.

So these are not forms to fill in. They are pages to take with you and tables to keep for years.

You can print any of these lists straight from the page, with Ctrl+P, or Cmd+P on an Apple computer. The menu, the footer and the illustration are left out, so you get the content on its own.

Before the appointment where the prescription is issued

Print it or copy it into your phone. The order matters, because the first three items decide the amount.

To settle during the appointment

• The mobility level the doctor enters on the prescription. Ask directly which one is going in and why that one. The limit follows from that single digit.
• The product code from the regulation. Write it down, you will need it with the prosthetics workshop and when applying for funding.
• Whether the prescription covers the prosthesis alone, or also the socket, liner and stump socks. These are sometimes separated.
• The date of issue and how long the prescription stays valid.

To take with you

• Hospital discharge summary from the amputation.
• Rehabilitation records, if you had any.
• Your disability certificate, if you already have one.
• The service documentation of your current prosthesis from the workshop, if this is not your first.

To write down after you leave, the same day

• What the doctor said about the mobility level.
• Any reservations raised, if there were any.
• When the next appointment is.

That last part looks pointless right up to the moment when, eight months later, you are trying to remember why the prescription says three and not four.

Legal basis and the details of the prescription itself

Prosthesis log

The most thankless thing on this page and at the same time the most useful. You keep it for years, it gives you nothing for the first two, and then it saves an application.

This is a log for your own use, not a warranty card. The workshop and the manufacturer keep their own documentation and that is what counts in a complaint. This sheet is here so that you know what to ask for and when.

In the header write down the type of prosthesis and level of amputation, the collection date confirmed on the prescription, the name of the workshop and the serial numbers of the modules: knee, foot and adapter. With microprocessor components the serial number is the only way to establish the software version and service history.

The log below prints from a computer with Ctrl+P, or Cmd+P on Apple hardware. From an Android phone: the three-dot menu, then Share, then Print. From an iPhone: the share icon on the bottom bar, scroll down, then Print. On a phone, turn the screen sideways first, the table has four columns. If you want the table on its own, without the other lists, set the page range in the print dialog.

What to record: every socket adjustment, every liner replacement, every software setting, every repair, and every visit where you raised something. For a visit, write down what you came in with, even if nothing was changed.

When you apply to shorten the replacement period, what counts is not the number of visits but whether the same symptom keeps returning. A sore spot in the same place, the socket rotating, the same adjustment made for the third time. Only that sequence shows that the scope for adjustment is running out, and it is visible only in a log kept as you go. Write down what the technician said as well, in their words. The dates and workshops in your log are then confirmed by the workshop documentation.

Preparing to shorten the replacement period

The regulation allows the replacement period for an adult to be shortened where their physical condition has changed in a way that requires new equipment, and the scope for adjusting the current device has been exhausted.

The patient does not file the request. It is issued by a doctor authorised to write the prescription, and it is the doctor who writes the medical justification. There is no form here for you to fill in. What you do influence is the material the doctor writes that justification from.

Change in physical condition

• Stump circumference today and in the month you collected the prosthesis, if you have it noted.
• Change in body weight over that period.
• Procedures, illnesses or complications that occurred in the meantime.
• What happens now when you walk. Chafing, pressure, the socket rotating, the stump slipping out when you sit down. Describe the symptom and the situation, do not make a diagnosis.

Scope for adjustment exhausted

• A list of every adjustment from the prosthesis log, with dates.
• How many times stump socks were added or removed over the past year.
• The workshop's position in writing, if the prosthetist considers the socket can no longer be fitted.

The second condition is proved almost entirely by the history of visits. Your prosthesis log points to the dates and the workshops, the workshop documentation confirms them. Without that you are left with your word against an absence of documentation.

Reimbursement rules and replacement periods in detail

Appealing against a disability certificate

Deadlines and the appeal route are set out on the certification page, so that they sit in one place. In short: fourteen days from service, you file with the district board and address it to the regional one.

One thing worth knowing before you write. The district board has seven days to pass the case on, and in that time it may change its own decision, if it finds the appeal well founded in full. That is a real chance to close the matter in two weeks instead of three months, but only where the letter makes clear what exactly you are asking for.

There is no compulsory form and the rules do not require detailed reasoning. It is enough that the letter shows you are dissatisfied with the decision. That is the minimum, not the recommendation.

What the letter should contain

• Your details and address.
• The number and date of the certificate.
• Addressee: the regional disability certification board.
• An indication of the route: through the district board.
• A sentence stating that you appeal against the certificate in whole or in part.
• What exactly you are contesting. The cause symbol, the degree, the point on the need for another person's help, the period the certificate covers.
• Short reasoning based on everyday functioning, not on medical terminology.
• A list of the documents you attach.
• Signature.

The panel assesses how you function, not your diagnosis. A sentence about an above knee amputation tells them less than a sentence about how many metres you walk without a rest, what you cannot do alone in the bathroom, and what happens on a day when you do not put the prosthesis on.

Documents for the certification application and the further appeal route

Reporting a fault to the prosthetics workshop

A phone call settles it in most cases. A letter makes sense when the fault keeps coming back, when the warranty is running out, or when you are preparing a request to shorten the replacement period.

• Date of the report.
• The workshop's details and yours.
• The prosthesis and the date you collected it.
• A description of the symptom, not the cause. “There is a knock from the foot side with every step, for about two weeks now” works better than “the joint is broken”.
• When the symptom first appeared and whether it is getting worse.
• What you have already tried and with what result.
• A request for an inspection date.

Keep a copy. Make the entry in your prosthesis log the same day.

Calendar of deadlines

• Seven days for the district board to pass an appeal on, and in that time it may change the decision itself.
• The replacement period runs from the collection date entered on the prescription, not from the date of issue. Several months can pass between the two.

Appeal deadlines in certification are on the certification page, so they are not duplicated in two places.

Application windows in the Active Local Government programme

Official forms

We deliberately do not keep copies of forms here. They change together with the rules, and some PFRON applications differ between districts and are filed electronically.

• Support Services System, filing PFRON applications - sow.pfron.gov.pl
• Active Local Government programme, conditions and deadlines - pfron.org.pl
• Disability certification, general information - gov.pl

You file an application for a certificate with the district disability certification board for your place of residence. Funding for orthopaedic devices is handled by the district family support centre, and in a city with district status usually by the municipal family or social support centre. The name of the office varies, the task is the same.

We do not maintain a list of local addresses here, because there are close to four hundred of them and they change independently of us. A link that has stopped working does more harm than good in a matter with a deadline.

Something does not add up?

Rules on reimbursement and certification change, and practice varies between districts and workshops. If any of this material has diverged from what you were told at the office or at the workshop, write to us. That covers an obvious error as much as a passage that is unclear or does not cover your case.

We read every report and reply to each one. Corrections go in together with the date of update.

Report an inaccuracy or an error

Legal position verified on 14 August 2026.

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