MEDICARE THERAPEUTIC SHOE PROGRAM RULES

Print Form:

1996 STATEMENT OF CERTIFYING PHYSICIAN FOR THERAPEUTIC SHOES

Patient's Name ______________________________________________

Medicare/HIC # ______________________________________________

I CERTIFY THAT ALL OF ALL OF THE FOLLOWING STATEMENTS ARE TRUE:

  1. This patient has diabetes mellitus. (250.0)
  2. This patients has one or more of the following conditions:(CIRCLE all that apply)
    1. History of partial or complete amputation of the foot (895.0)
    2. History of previous foot ulceration. (707.1)
    3. History of pre-ulcerative callus (707.9)
    4. Peripheral Neuropathy w/evidence of callus formation (356.4)
    5. Existing foot deformity ( 736.7)
    6. Poor circulation (443.9)
  3. I am treating this patient under a comprehensive plan of care for his/her diabetes.
  4. Choose one:
    a) this patient needs depth shoes and inlays because of his/her diabetes
    b) due to serious foot deformity and diabetes, this patient requires custom molded shoes.

PHYSICIAN'S SIGNATURE_____________________________________ DATE: _________________

PHYSICIAN'S UPIN: __________________________

Print:
Physician's name:
Office address:

Please fax to : A Custom Comfort Shoes (954) 454-9971

OR mail to: A Custom Comfort Shoes 1452 E. Hallandale Beach Blvd. Hallandale, Fl 33009