Physician Certification/prescription Form - Blue Ridge Pharmacy printable pdf download

PHYSICIAN CERTIFICATION / PRESCRIPTION

AND PATIENT AOB / ACCEPTANCE FOR THERAPEUTIC FOOTWEAR

NAME:

DOB

HIC#

Chart#

ADDRESS:

City

State

Phone #:

I CERTIFY THAT ALL THE FOLLOWING STATEMENTS ARE TRUE:

1. This patient has diabetes mellitus. ICD -9 Code ( Check all that apply )

250.00 - Diabetes mellitus type II ( NIDDM type ) ( adult - onset type ) or unspecified type, not stated as controlled

250.01 - Diabetes mellitus type I ( IDDM ) ( juvenile type ), not stated as uncontrolled

250.02 - Diabetes mellitus type II ( NIDDM type ) ( adult onset type ) or unspecified type, uncontrolled

250.03 - Diabetes mellitus type I ( IDDM ) ( juvenile type ), uncontrolled

Other ICD - 9 Codes / Notes:

2. This patient has one or more of the following conditions: ( check all that apply )

** This should be consistent with the encounter forms and " diabetic patient summary, tracking, and schedule sheet."

* History of partial or complete amputation of the foot

* Foot deformity

* History of previous foot ulceration

* Poor circulation

* History of pre-ulcerative callus

* Peripheral Neuropathy with evidence of callus formation

3. I am treating this patient under a comprehensive plan or care for his/her diabetes.

4. This patient needs special shoes ( depth or custom-molded shoes ) because of his/her diabetes.

# UNITS

HCPCS Code

Prescription / Description

1 2 3 4

A5500

For diabetics only, fitting ( including follow-up), custom preparation and supply of the off the shelf

depth inlay shoe manufactured to accommodate multi density insert (s), per shoe

2 3 4 6

A5512

For diabetics only, multiple density insert (s), per shoe

2 3 4 6

A5513

For diabetics only, multiple density custom fabricated insert (s),molded and formed directly to a

model of the patient's foot.

M.D. / D.O. - Prescribing Physician Signature: ________________________ Date:__________

Physician Information

Name:

Address:

NPI:

Office #:

Office Fax #:

Employee Certification

I certify, (a) the above named patient has received the above marked shoes and /or inserts (b) that the documentation contained in the chart is

consistent with the diagnosis and conditions marked on this form ( c ) that the patient's condition (s) and diagnosis (s) have been explained to the

patient and every reasonable effort has been made to insure the patient understands their diagnosis (s) and condition (s); (d) the patient has been

fitted and has accepted and is satisfied with the shoes and inserts provided for them.

Date:_______________________________

Signature: __________________________________________________________

Patient Certification

I certify, (a) I have received the above marked therapeutic shoes and inserts, ( b ) my condition ( s ) and diagnosis ( s ) have been explained to me.

( c ) I understand the importance of self care and compliance with the treatment plan by my physician. ( d ) I am satisfied with the shoes and inserts

I received from this health care provider. ( e ) I have been given the option of having the shoes and inserts provided by another provider but

have elected to have them provided by this physician/ facility. This facility has my permission to file for and receive reimbursement from my

insurance carrier (s) in my behalf. I further certify the information recorded above is true and correct. I understand I am responsible for non covered

or unpaid services.

Date:___________________________

Signature:___________________________________________

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