Diabetic Verification Form printable pdf download

Prescription for Therapeutic Footwear

Diabetic Verification Form

(MD, DO, DPM, NP, PA, CNP)

(MD or DO Only)

Patient Name: ____________________________ Chart #: ___________

Patient Name: _______________________________ DOB: _____________

DOB: _____________________

Today’s Date: ________________

I certify that all of the following statements are true:

Check all that apply:

1) This patient has diabetes mellitus. ICD-9 Code: ____________

(ICD-9 codes 250.00 – 250.93)



Edema (

Diabetes Mellitus:

_____

782.3)

ICD-9:

2) This patient has one of the following conditions:



Neuroma

(ICD-9 codes 250.00-250.93)

(997.61)

(check all that may apply)



Hammertoe(s)

(735.4)



Corn(s)

(700)



Bunion(s)

(727.1)



Ankle Instability

(718.87)



History of partial or complete amputation of the foot



Ulcer(s) (

707. – 8/9/14/15)



Drop Foot

(736.79)



Peripheral neuropathy with evidence of callus formation



Callus(es)

(700’s)



Posterior Tib. Disorder

(727.06)



History of previous foot ulceration



Amputation(s) (

896. - 1/2)



Peripheral Vascular Disease

(443.9)



Foot deformity



Charcot Deformity

(713.5)



Neuropathy

(337.1)



Plantar Fascitis



History of pre-ulcerative callus

(728.71)



Poor circulation



Other: ___________________________________________________

The patient requires:

3) Within the past 6 months, an exam has been performed and

qualifying condition(s) have been documented.



Diabetic Footwear, non custom (A5500) – 1 pair

(unless otherwise indicated)

With:

4) I am treating this patient under a comprehensive plan and care for

his/her diabetes.



Custom molded inserts (A5513) – 3 pairs

(unless otherwise indicated)

Lesions requiring offloading:

L 1 2 3 4 5

5) This patient needs special shoes (depth or custom-molded) and/or

R 1 2 3 4 5

inserts because of his/her diabetic condition.



Non custom, heat moldable inserts (A5512) – 3 pairs

(unless otherwise

Certifying Physician Information:

(must be signed by a MD or DO)

indicated)



Toe Filler (L5000)

Signature: ____________________________ Date: ______________

Comments: ___________________________________________________

Name: ____________________________________________________

____________________________________________________________

_____________________________________________________________

Address: __________________________________________________

Clinician Name: _______________________________________________

NPI #: _____________________________________________________

Signature: ______________________________ ____

Date: __________

Signature: ______________________________

Date: __________

*PLEASE FAX TO: Great Steps O&P Solutions – 320-229-1671*

Diabetic Verification Form

Related Articles

Related forms

Related Categories