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#:

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