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You may print this form and have your Doctor complete it. After the form is completed by your Doctor, you may bring it with you to any of our servicing locations.
 
 
Dear Doctor:
Your patient has requested us to invoice Medicare for his/her diabetic footwear and appropriate multi-density insoles. In order for us to accommodate your patients' needs, proper documentation must be provided. Please fill out and SIGN the Statement of Certifying Physician for Therapeutic Shoes. Also, please provide an original prescription OR complete and SIGN the prescription provided on the bottom of this page.

Statement of Certifying Physician for Therapeutic Shoes

Patient Name: ________________________________________________
HIC(Medicare ID)#: ___________________________________________
I certify that all of the following statements are true:
1. This patient has diabetes mellitus -- ICD-9 Code: ___________________ (ICD-9 diagnosis codes 250.00-250.91)
2. This patient has one or more of the following conditions (circle all that apply):
a. History of partial or complete amputation of the foot
b. History of previous foot ulceration
c. History of pre-ulcerative callus
d. Peripheral neuropathy with evidence of callus formation
e. Foot deformity
f. Poor circulation
3. I am treating this patient under a comprehensive plan of care for his/her diabetes.
4. This patient needs special shoes (depth or custom-molded shoes) and/or inserts because of his/her diabetes.
Physician signature: _________________________________ Date signed: ________________
Physician name (print): _______________________________ Physician UPIN: ____________
Physician address: ______________________________________________________________
 

Prescription Form
 

Patient Name: ___________________________________________________
Extra-Depth Shoes with three pairs of Multi-Density Inserts

*Medicare allows one pair of Extra-Depth Shoes per calendar year and three pairs of Multi-Density Inserts per year
Physician signature: _________________________________ Date signed: ________________
Physician name (print): _______________________________ Physician UPIN: ____________
Physician address: ______________________________________________________________