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Prescription Form for Therapeutic Footwear
(Prescribing physician may be different from certifying physician.)
Patient Name:
HIC#:
Address:
Diagnosis:
Change to be effected:
Additional relevant information, such as systemic conditions or allergies to specific materials:
Prescribing Physician Information
Signature:
Date:
Name:
DEA#:
Medicare UPIN#:
Medicaid Provider#:
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![NDEP logo](https://webarchive.library.unt.edu/eot2008/20080917220901im_/http://ndep.nih.gov/images/logo_NDEP_med.gif)
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.
Learn how to prevent or delay type 2 diabetes through small steps.
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