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Statement of Certifying Physician for Therapeutic Footwear
Patient Name:
HIC #:
Address:
I certify that all of the following statements are true:
This patient has diabetes mellitus. -ICD-9 Code: _________________
(ICD-9 diagnosis codes 250.00-250.93)
This patient has one or more of the following conditions (check all that apply):
_____ History of partial or complete amputation of the foot
_____ Peripheral neuropathy with evidence of callus formation
_____ History of previous foot ulceration
_____ Foot deformity
_____ History of pre-ulcerative callus
_____ Poor circulation
I am treating this patient under a comprehensive plan of care for his/her diabetes.
This patient needs special shoes (depth or custom-molded shoes) and/or inserts because of his/her diabetes.
Certifying Physician Information
Signature:
Date:
Name:
DEA #:
Medicare UPIN #:
Medicaid Provider #:
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National Diabetes Education Program (NDEP) http://ndep.nih.gov
NIDDK, National Institutes of Health, Bethesda, MD
A Joint Initiative of the National Institutes of Health and the
Centers for Disease Control and Prevention |
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Includes information about managing the ABCs of Diabetes. Also features information for people with diabetes who are eligible for Medicare benefits.
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Learn how to prevent or delay type 2 diabetes through small steps.
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