Statement of Certifying Physician for Therapeutic Footwear

Patient Name:

HIC #:

Address:

I certify that all of the following statements are true:

1. This patient has diabetes mellitus. -ICD-9 Code: _________________
   (ICD-9 diagnosis codes 250.00-250.93)

2. 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

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

4. 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 #:

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