STATEMENT OF CERTIFYING PHYSICIAN DIABETIC THERAPEUTIC FOOTWEAR
(This form must be signed by the D.O. or M.D. caring for the patient’s diabetic condition.)
PATIENT:_____________________________________________________________________________
PHONE:______________________________________________
DATE:_____________________
MEDICARE #:__________________________________________________________________________
SUPPLEMENT #:_______________________________________________________________________
I certify that all of the following indicated statements are true and are noted in the patient’s chart. (check all that apply):
1. This patient has diabetes mellitus. ICD9: Code__________________________(250.00 – 250.91)
2. This patient has one or more of the following conditions (CHECK ALL THAT APPLY)
_____ A. History of partial or complete amputation of 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
2. I am treating this patient under a comprehensive plan of care for Diabetes.
3. This patient needs special footwear (depth or custom molded footwear) and / or inserts because of their
diabetic condition.
4. This patient is _______ insulin dependent / ________ non-insulin dependent.
Physicians Signature:________________________________________________ Date:_______________
Physicians Name (printed):_________________________________________________________________
Physicians Address:______________________________________________________________________
Physicians Phone:_______________________________NPI_____________________________________
THESE ARE 2 SEPARATE FORMS AND BOTH MUST BE FILLED OUT IN ENTIRETY
Prescription Form for Therapeutic Footwear
(Prescribing physician may be a D. O., M. D. or D. P. M. and may be different from certifying physician.)
PATIENT:__________________________________________________ DOB:____/_____/______
Prescription:
__________
1 Pair Extra Depth Shoes (A5500)
__________
3 Pair of Heat Moldable Inserts (A5512)
__________
3 Pair of Custom Molded Orthotics (A5513)
Physicians Signature:________________________________________________ Date:_______________
Physicians Name (printed):_________________________________________________________________
Physicians Address:______________________________________________________________________
Physicians Phone:_______________________________NPI_____________________________________